Gastroenterology Flashcards
Who should be screened for Barrett’s esophagus?
Men with 5+ years of GERD and 2+ risk factors (age>50, white, obese, smoker, FHx BE/esophageal Ca).
What method of endoscopic ablation is indicated for low grade non-nodular Barrett’s esophagus?
Radiofrequency ablation.
Name 3 surgical and 3 non-surgical treatments for achalasia.
Surgical: pneumatic dilatation, myotomy (e.g. POEMS), esophagectomy.
Medical: botulinum toxin, nitrates, calcium channel blockers.
What clinical features suggest eosinophilic esophagitis?
Young male with atopy and solid food dysphagia +/- food boluses.
How do you treat eosinophilic esophagitis?
Dietary elimination (eggs, soy, cow’s milk, wheat, tree nuts, seafood), topical steroids with water rinse.
How do you work someone up for celiac disease if they are IgA deficient?
Anti-gliadin (DGP) antibody and anti-TTG IgG, if positive then duodenal biopsy.
What features suggest severe ulcerative colitis?
> 6 movements per day, urgency, frequent blood, anemia, ESR>30, elevated CRP and fecal calprotectin.
What are maintenance options for moderate to severe ulcerative colitis?
Azathioprine, anti-TNFs, tofacitinib (JAK2 inhibitor), vedolizumab (Entyvio, anti-integrin)
How do you diagnose toxic megacolon?
- Colon > 6cm AND
- 3+ fever, HR>120, anemia, neutrophils >10.5 AND
- 1+ of dehydration, electrolyte abnormalities, hypotension, altered LOC.
Which therapies are not indicated for Crohn’s?
5-ASA (but can use sulfasalazine) and tofacitinib.
What are induction options for Crohn’s disease?
IV steroids, methotrexate, anti-TNFs.
How do you treat strictures in Crohn’s disease?
Cold stricture: conservative (NGT, IV fluids, pain management), dilatation or surgery. Hot stricture (mesenteric adenopathy, fat stranding, elevated inflammatory markers): steroid bridge to anti-TNF.
Describe Type 1/pauciarticular IBD arthritis.
More common than type 2, <5 joints affected, usually large joints, flare lasts <10 weeks, flare parallels IBD activity.
Who gets 72 hours IV PPI post-endoscopy?
Bleeding vessels, visible vessels, non-removable adherent clot.
Who should get indefinite PPI therapy after a non-variceal bleed?
On ASA for secondary prevention, on anticoagulation, unclear etiology of peptic ulcer disease.
Who should you screen for H. pylori?
PUD, MALT lymphoma, gastric cancer, long term ASA or NSAID use, unexplained iron deficiency, ITP.
What are two first line therapies for H. pylori infection?
PBMT or PAMC for 14 days.
What is the window period in hepatitis B?
Viral is clearing and HBsAg is negative, but HBsAb has not become positive yet.
Which chronic Hep B patients get HCC screening with U/S every 6 months?
- Asian men, HIV+, family Hx HCC > 40 years.
- Asian women > 50 years.
- Black patients > 20 years.
- All cirrhotics.
If HBeAg is negative, what is the HBV DNA cut-off for starting treatment?
> 2000 IU/mL (>20,000 if HBeAg positive).
What are two first line treatments for hepatitis B and how long do you treat for?
Tenofovir and entecavir. Treat for life usually.
List three extrahepatic manifestations of hepatitis B.
Aplastic anemia, membranous nephropathy, polyarteritis nodosum.
What are four disease-specific risk factors for hepatitis B becoming either cirrhosis or hepatocellular carcinoma?
- High liver enzymes.
- Prolonged time to eAg seroconversion
- eAg negative mutant.
- Genotype C.
What metric is used to determine hepatitis C cure?
SVR12 = sustained viral response at 12 weeks after completing therapy.
Name two direct-acting antivirals used for hepatitis C.
Epclusa and Maviret.
Name 4 autoimmune and 4 hematologic extrahepatic manifestations of hepatitis C.
Autoimmune: diabetes, myastenia gravis, sjogren’s, thyroid disease.
Hematologic: hemolytic anemia, cryoglobulinemia, lymphoma, ITP.
What are the Maddrey discriminant function and Lille score cut-offs in treating alcoholic hepatitis?
If Maddrey score >32 - start prednisolone 40 mg po daily x 28 days. If Lille score <0.45 on day 7 then continue therapy, otherwise stop (Lille low = lucky).
Name 3 interventions for treatment of NAFLD/NASH.
- Lose 3-5% body weight, may require bariatric surgery.
- Pioglitazone and vitamin E in NASH only.
- Aggressive cardiovascular risk reduction.
What MELD score should be referred for liver transplant?
MELD>15
What three screening tests should be performed upon diagnosis of cirrhosis?
Endoscopy for varices, U/S for HCC, paracentesis if ascites) for SBP.
Who gets non-selective beta blocker therapy for varices?
Primary prophylaxis: small varices that are high risk (Child Pugh C, red wale, red spot), medium to large varices (can do EVL instead).
Secondary prophylaxis: along with EVL.
What causes SAAG>11?
Portal hypertension: cirrhosis, liver mets, portal vein thrombosis.
What are two contraindications to TIPS?
Hepatocellular carcinoma, encephalopathy.
How do you diagnose spontaneous bacterial peritonitis?
Ascitic neutrophils>250 OR positive culture and no other secondary causes.
Who gets SBP prophylaxis?
- Prior SBP.
- Cirrhosis with variceal bleed.
- Ascitic albumin < 15 and either renal (Cr>106, BUN>8.9, Na<130) or liver (bili>51 AND Child-Pugh>9) impairment.
What are the two types of autoimmune pancreatitis?
Type 1: IgG4-mediated (older men, sausage-shaped pancreas, biliary strictures, other IgG4 organs involved).
Type 2: isolated pancreatic disease, associations with IBD.
Who do you screen for hereditary hemochromatosis?
First degree relatives of a diagnosed HH case (homozygous at C282Y).
What are the phlebotomy targets for hemochromatosis treatment?
Ferritin < 100 in men and < 50 in women.
How do you diagnose primary biliary cholangitis?
PBC - middle aged woman with jaundice, pruritis, fatigue.
Diagnose with 2+ of ALP elevated >6 months, AMA>1:40, liver biopsy.
How do you diagnose hepatorenal syndrome?
Patients with chronic liver disease with:
- Rising Cr and oliguria
- Bland sediment and proteinuria <0.5 g/d
- Urine sodium < 20
- Ruled out ATN, nephrotoxins, obstruction
- No response to stopping diuretics and trialling albumin for 2d
What are complications of PPI?
C diff, pneumonia HypoMg, Low B12 AIN/CKD Dementia Low BMD Gastric Ca
What is the management of indefinite esophageal dysplagia on OGD for Barrett’s?
Optimize PPI, then EGD.
If still indefinite, repeat bx in 1 year
If histology changed, manage per new histology
When and how long do you do SBP prophylaxis in UGIB?
Both non variceal and variceal bleed in setting of cirrhosis.
Ceftriaxone 1g Q24h x up to 7 days or till when octreotide stops
Who should you screen for Hep C?
Risk factor based screening:
IVDU/incarceration/sexual contact/HIV/MSM
Healthcare worker
Transfusion prior to 1992
Born to mother with Hep C or endemic areas
How do you manage scope-proven esophagitis?
PPI and lifestyle changes, monitor lifestyle changes, increase to BID if refractory, switch PPI if refractory past 8 weeks.
What are the findings of hemochromatosis:
Tan, arthralgias, chondrocalcinosis of 2nd and 3rd MCP, neuropathy, cardiomyopathy, diabetes, hypopituitarism, hypogonadism
