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MCCQE1 > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

45-y-o woman, BMI 35 with colicky abdominal pain in right upper quadrant that radiates to the shoulder, worse when eating fatty food. Dx, next step and tx?

A

Cholelithiasis

Next step: RUQ U/S (which would show gallstone)

Tx:

  • Elective cholecystectomy
  • If non-surgical candidate –> ursodeoxycholic acid
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2
Q

Patient with constant RUQ pain, (+) murphy sign, mild leucocytosis. Dx, next step and tx?

A

Cholecystitis

Next steps:

  • RUQ U/S (Pericholecystic fluid, thickened wall, gallstones)
  • If inconclusive U/S –> HIDA scan: failure to fill the gallbladder is a positive test

Tx:

  • NPO, IVF, IV antibiotics (Ciprofloxacin + metronidazole; or ampicilin-gentamicin + metronidazole)
  • Urgent cholecystectomy (within 72 hours)
  • If non-surgical candidate –> cholecystostomy
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3
Q

Painful jaundice, murphy sign, mild leucocytosis, ↑AST, ↑ALT, ↑amylase. Dx, next step and tx?

A

Choledocholithiasis

Next steps:

  • RUQ U/S showing dilated ducts
  • Magnetic resonance cholangiopancreatography (MRCP)

Tx:

  • NPO, IVF, IV antibiotics (Ciprofloxacin + metronidazole; or ampicilin-gentamicin + metronidazole)
  • Urgent ERCP (Endoscopic Retrograde Cholangio-Pancreatography)
  • Elective cholecystectomy
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4
Q

RUQ pain, fever, jaundice. Dx, next step and tx?

A

Cholangitis

Next steps:

  • RUQ U/S showing dilated ducts
  • Don’t do HIDA or MRCP

Tx:

  • Emergent ERCP, which is both diagnostic and therapeutic
  • NPO, IVF, IV antibiotics (Ciprofloxacin + metronidazole; or ampicilin-gentamicin + metronidazole)
  • Urgent to elective cholecystectomy
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5
Q

Charcot triad?

A

RUQ pain
Fever
Jaundice

Dx: Cholangitis

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6
Q

Reynolds pentad?

A

RUQ pain
Fever
Jaundice
Hypotension
Altered mental status

Dx: Severe cholangitis

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7
Q

Can pip/tazo be used for gallbladder deases?

A

Don’t pick this in the test because it’s expensive and you would be overcovering for gram positives (o Organisms in biliary tree are gran negative rods and anaerobes)

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8
Q

Odynophagia, dysphagia + history of taking NSAIDS, Antibiotics (tetracyclins), Biphosphonades, or HAART. Dx, next step and treatment?

A

Pill induced esophagitis

Next step: EGD + Bx

Tx: Remove medication, time to heal, PPI

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9
Q

Odynophagia, dysphagia, oral thrush. Dx, next step and treatment?

A

Infectious esophagitis (Candida)

Next step: EGD + Bx

Tx: fluconazole or nystatin oral suspension

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10
Q

Odynophagia, dysphagia, oral vesicles on erythematous base in multiple stages of healing . Dx, next step and treatment?

A

Infectious esophagitis (HSV)

Next step: EGD + Bx

Tx: Valacyclovir or acyclovir

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11
Q

Odynophagia, dysphagia, CMV on EGD Bx. Treatment?

A

valganciclovir

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12
Q

Patient with history of Asthma, seasonal Allergies, Atopy (eczema) + Odynophagia, dysphagia. Dx, next step and treatment?

A

Eosinophilic esophagitis

Next step: EGD + Bx with > 15 eosinophils/high-power field

Tx:

  • Trial of PPI x 6 if not on PPI before
  • If on PPI before or trail fails–> Oral aerosolized steroids
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13
Q

Kid who by accident drink drain cleaner, hoorse or stridor (larynx burn), Drooling. Dx and next step?

A

Caustic esophagitis

Next step: Intubate!!! then EGD + Bx to determine the severity

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14
Q

Adult in a suicide attempt who drank drain cleaner, hoorse, drooling. Dx and next step?

A

Caustic esophagitis

Next step: Intubate!!! then EGD + Bx to determine the severity

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15
Q

Low severity caustic esophagitis management?

A

In early stages, NGT and lavage
Low severity: liquid diet

NEVER NEUTRALIZE THE pH
NEVER INDUSE EMESIS

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16
Q

High severity caustic esophagitis management?

A

In early stages, NGT and lavage
High severity: NPO x 72 hours and then repeat EGD

NEVER NEUTRALIZE THE pH
NEVER INDUSE EMESIS

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17
Q

Patient under 50, Dysphagia for solids and liquids.

Bird’s beak of barium sallow
Sustained LED contraction on manometry

Dx, next step, treatment and follow up?

A

Achalasia

Next step: EDG + Bx

Tx: Myotomy is the election tx
- Botulinum toxin only when non-surgical candidate

Follow up: treat iatrogenic GERD

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18
Q

Woman, Dysphagia for solids and liquids, Calcinosis, Reynold’s, Sclerodactyly, Telangiectasia, GERD.

Dx, next step, tx?

A

Scleroderma

Next steps:

  • barium sallow–> LES wide open
  • manometry –> No esophageal activity
  • EGD + Bx

Tx: PPI

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19
Q

Patient with recurrent episodes of crushing retrosternal chest pain that betters with Nitroglycerin and CCB. Enzimes are always negative.

Dx, next step, tx?

A

Diffuse esophageal spasm

Next steps:

  • Barium sallow–> Corkscrew esophagus
  • Manometry–> diffuse uncoordinated contractions
  • EGD + Bx

Tx:
• CCB
• Nitrates PRN

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20
Q

Patient with intermitent disphagia of solid food (big bites).

Dx, next step, tx?

A

Schatzki’s Ring

Next steps:

  • Barium sallow-> narrow lumen
  • EGD + Bx-> rule out cancer and shows the ring

Tx: Lyse the ring during EGD

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21
Q

Woman, Dysphagia for solids then liquids, Iron deficiency anemia.

Dx, next step, tx?

A

Plummer-Vinson

Next step:
- Barium sallow showing Esophageal webs (no need for EGD for Dx)

Tx:
• Iron
• Frequent EGD + Bx as screening tool for esophageal cancer

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22
Q

Old man, Halitosis, Regurgitation of undigested food, Dysphagia for solids then liquids.

Dx, next step, tx?

A

Zenker’s diverticulum

Next step:

  • Barrium sallow
  • EGD + Bx

Tx: Surgery

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23
Q

Long-lasting GERD, Progressive dysphagia, Weight loss

Barrium sallow–> symetric/circumferential loss of lumen

Dx and tx?

A

Stricture

Tx:

  • High-dose PPI
  • Dilation
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24
Q

Long-lasting GERD, Progressive dysphagia, Weight loss

Barrium sallow–> asymmetric loss of lumen

Dx?

A

Esophagus Adenocarcinoma

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25
Q

Patient with a history of alcohol consumption, a heavy smoker, Progressive dysphagia, Weight loss

Barrium sallow–> asymmetric loss of lumen

Dx?

A

Squamous cell carcinoma

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26
Q

Patient with Nocturnal asthma symptoms that are absent during day, coughing and hoarseness. Dx and next step?

A

GERD

Next step: PPI + lifestyle changes x 6 weeks

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27
Q

Patient with Burning chest pain, Worsens laying down and with spicy food, Nausea, Vomiting, Macrocytic Anemia, and Weight loss. Dx and next step?

A

GERD with alarm symptoms

Next step: EGD + Bx

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28
Q

GERD on EGD. Tx?

A

PPI

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29
Q

Intestinal metaplasia (Bartlett’s) on EGD. Tx?

A

↑PPI (BID) + Annual EGD

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30
Q

Dysplasia on EGD. Tx?

A

local ablation +PPI + annual EGD

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31
Q

Adenocarcinoma on EGD. Tx?

A

Resection/chemo + radiation

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32
Q

Patient with GERD who doesn’t tolerate PPI. Next step?

A

Surgery (Nissen fundoplication)

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33
Q

Patient with gnawing epigastralgia.

EGD: Single large ulcer on duodenum. Possible dx?

A

H. Pylori

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34
Q

Patient with gnawing epigastralgia.
EGD: Multiple shallow ulcers.
Possible dx?

A

NSAIDs

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35
Q

Patient with gnawing epigastralgia.
EGD: ulcers with necrotic base heaped margings
Possible dx?

A

Malignancy

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36
Q

Patient with gnawing epigastralgia and diarrhea.
EGD: Multiple refractory ulcers
Possible dx?

A

Gastrinoma/Zollinger-Ellison

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37
Q

Patient with dyspepsia and PUD. Never treated before for H. Pylori.
Best dx test?

A

Serology

Because never treated before and currently having Sx. If positive, treat immediately

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38
Q

Patient with dyspepsia and PUD. Treated before for H. Pylori.
Best dx test?

A

EGD + Bx (histology)

Not urease test. Histology it’s better

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39
Q

Patient who has finished treatment for H. Pylori. Test to confirm erradication?

A

Stool Ag

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40
Q

Treatment for H. Pylori?

A

Triple therapy

  1. Clarithromycin
  2. Amoxicillin (or metronidazole if allergic)
  3. PPI
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41
Q

Patient with refractory gastric ulcers and diarrhea.

Dx, next steps, tx?

A

Gastrinoma/Zollinger-Ellison

Next steps:
1. Gastrin level > 1600 (normal < 250)
•Between 250 and 2600, do a Secretin stimulation test

  1. Localize the tumor with an Somatostatin receptor Scintigraphy (SRS) (AKA, Octreotide scan)

Tx: resection

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42
Q

Complication of Gastrinoma/Zollinger-Ellison

A

Gastric malignancy

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43
Q

Diabetic patient with chronic nausea and vomiting, abdominal pain when eating and peripheral neuropathy. Dx, next step, tx?

A

Gastroparesis

Next steps:

  • EGD to r/o ca, obstruction of outlet and GERD
  • Emptying study: Positive if >60% on stomach after 2 hrs or > 10% after 4 hours
Tx:
Avoid opiates, anticholinergics
Manage blood glucose 
Prokinetic agents
•	Metoclopramide PO in chronic management
•	Erythromycin IV in acute management
Low fiver, small volume meals
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44
Q

Tx of gastroparesis

A 
Low fiver, small volume meal
Avoid opiates, anticholinergics
Manage blood glucose 
Prokinetic agents
•	Metoclopramide PO in chronic management
•	Erythromycin IV in acute management
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45
Q

Marihuana smoker with nausea and vomiting that last a few days, then disapears and then come again. Dx and tx?

A

Cyclic vomiting syndrome

Tx:

  • Stop THC
  • Metoclopramide or Erythromycin
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46
Q

Patient with early satiety, weight loss, nausea and vomiting. Dx, next step?

A

Gastric carcinoma

Next steps:

  • EGD + Bx
  • PET scan to stage
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47
Q

What is a MATLoma and tx?

A

Gastric lymphoma produced by H. Pylori. Treated with triple therapy: Clarithromycin, Amoxicillin (or metronidazole if allergic), and PPI

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48
Q

Watery diarrhea, 3rd world country, no boiling water. Likely cause of diarrhea?

A

Vibrio cholera

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49
Q

Patient who comes from a trip to central america and has watery diarrhea. Likely cause of diarrhea?

A

ETEC (Enterotoxigenic E. Coli)

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50
Q

Patient with watery diarrhea who was on a picnic, he ate egg salad and potato salad. Likely cause of diarrhea?

A

S. Aureus

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51
Q

Patient with watery diarrhea who ate at a Chinese buffet and ate reheated rice. Likely cause of diarrhea?

A

Bacillus cereus

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52
Q

Patient how was hiking and drank fresh water. Now has watery diarrhea. Likely cause of diarrhea?

A

Giardia

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53
Q

Patient with diarrhea, fever and abd pain. Ate raw chicken. Likely cause of diarrhea?

A

Salmonella

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54
Q

Patient with bloody diarrhea, fever and abd pain. Likely cause of diarrhea?

A

Entamoeba histolyctica

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55
Q

Patient with HIV/AIDS and diarrhea. Likely cause of diarrhea?

A

Cryptosporidium

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56
Q

What is the most common cause of bloody diarrhea ?

A

Campylobacter

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57
Q

Red flags in diarrhea?

A 
Fever
Severe dehydration
Bloody stool
Pus on stool
Recent travel
Duration of more than 3 days
Severe abdominal pain
Recent hospitalization
History of IV antibiotics
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58
Q

Patient with bloody diarrhea, Fever, Severe dehydration,

Duration of more than 3 day, and Severe abdominal pain. Next step?

A

C. diff NAAT
Fecal leukocytes
Fecal occult blood
Ova + Parasites

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59
Q

Stable hospitalized patient witn watery smelly diarrhea. Dx, next step and tx?

A

C. Difficile

Next step: C. diff NAAT

Tx:

  • Stop culprit ab
  • IV fluids
  • Vacomycin or fidaxomicin (MTZ only if these meds are not available)
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60
Q

Hospitalized patient witn watery smelly diarrhea, hypotensive, toxic megacolon, paralytic ileus, or an elevated lactate. Dx, next step and tx?

A

C. Difficile

Next step: C. diff NAAT

Tx:

  • Stop culprit ab
  • IV fluids
  • ↑PO (or PR) Vancomycin + IV MTZ
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61
Q

Patient with bloody diarrhea, who a week after is pale, and has edema. • Petechiae and HTN on physical exam.
Dx, next step, and tx?

A

Hemolytic uremic syndrome

Next step:

  • CBC
  • Blood smear to confirm hemolytic anemia
  • Renal function, uroanalysis
  • Shigella toxic assay

Tx:

  • Supportive
  • Plasma exchange
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62
Q

Patient with diarrhea of > 4 weeks of duration. First differentials to think of?

A

Medications
Laxatives
Lactose deficency
C. Diff chronic infection

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63
Q 
Patient with diarrhea of > 4 weeks of duration. 
Osm Gap       < 50
Fecal WBC	(-)
Fecal RBC	(-)
Mucus	(-)
△ NPO	No difference
Nocturnal Sx	(+)
Fecal fat	(-)

Type of diarrhea and differential?

A

Secretory

Differential:

  • VIPoma
  • Gastrinoma
  • Carcinoid
  • C- Diff
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64
Q 
Patient with diarrhea of > 4 weeks of duration. 
Osm Gap       > 100
Fecal WBC	(-)
Fecal RBC	(-)
Mucus	(-)
△ NPO	Improves
Nocturnal Sx	(-)
Fecal fat	(+/-)

Type of diarrhea and differential?

A

Osmotic

Differential:

  • Celiac
  • Lactose def
  • Malabsoption
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65
Q

Patient with diarrhea of > 4 weeks of duration.
Fecal WBC (+)
Fecal RBC (+)
Mucus (+)

Type of diarrhea and differential?

A

Inflammatory

DIfferential:

  • Chron’s
  • Ulcerative colitis
  • Radiation colitis
  • Diverticulosis
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66
Q

Patient with right-sided heart fibrosis, flushing, and chronich diarrhea. Dx and next step?

A

Carcinoid (Tumor in the liver that secretes serotonin into the portal veins)

Next step: Urinary 5 HIAA (metabolite of serotonin)

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67
Q

Folate. Place of absorption and sx of deficiency?

A

Duodenum

megaloblastic anemia

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68
Q

Iron. Place of absorption and sx of deficiency?

A

Duodenum

microcytic anemia

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69
Q

Calcium. Place of absorption and sx of deficiency?

A

Duodenum

osteoporosis

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70
Q

Vit A. Place of absorption and sx of deficiency?

A

Terminal ileum

night blindness

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71
Q

Vit D. Place of absorption and sx of deficiency?

A

Terminal ileum

osteoporosis

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72
Q

Vit E. Place of absorption and sx of deficiency?

A

Terminal ileum

nystagmus

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73
Q

Vit K. Place of absorption and sx of deficiency?

A

Terminal ileum

bleeding

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74
Q

Patient with Diarrhea, Distension, Weight loss, and Extremely itchy bumps and blisters that appear on both sides of the body, most often on the forearms near the elbows, as well as on knees and buttocks, and along the hairline.

Dx, next step and tx?

A

Celiac sprue

Next steps:

  • Anti-transglutaminase (TTG) antibodies
  • EGD + Bx= atrophic villi

Tx: 3-4 months of avoiding gluten: Avoid wheat, rye (centeno), oat, barley (cebada)

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75
Q

Diarrhea, Flatulence, Distension, No weight loss. Dx?

A

Lactose intolerance

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76
Q

Caribbean farmer with Diarrhea, Distension, Weight loss, and Extremely itchy bumps and blisters that appear on both sides of the body, most often on the forearms near the elbows, as well as on knees and buttocks, and along the hairline. Doesn’t improve with gluten-free diet.

Dx?

A

Tropical sprue

77
Q

Diarrhea, distension, Ataxia, memory loss, seizures, Joint pain, Lymphadenopathy. Dx, next step and tx?

A

Whipple’s disease

Next step:
- EGD + Bx: Pas (+) macrophages

Tx: Tmx-smp or doxycycline

78
Q

Western patient over 50, constipation. Diverticulosis on colonoscopy. Tx?

A

High-fiber diet rich in fruits and vegetables

79
Q

Patient over 50 with postprandial LLQ abdominal pain that is relieved with bowel movement. Dx and tx?

A

Symptomatic, uncomplicated diverticulosis/ Diverticular spams

Tx: High-fiber diet rich in fruits and vegetables

80
Q

Patient with LLQ abd pain, Fever, ↑wbc and Tender abdomen. Dx and next steps?

A

Diverticulitis

Next steps:

  • Upright KUB to r/u perforation
  • CT scan of abdomen with IV contrasts to determine the severity
81
Q

Patient with LLQ abd pain, Fever, ↑wbc and Tender abdomen and free air on KUB. Dx and tx?

A

Perforated diverticulitis

  • Surgery
  • IV Cipro + mtz or Gent/ampicillin + mtz
82
Q

Patient with LLQ abd pain, Fever, ↑wbc and Tender abdomen and air-fluid levels on KUB. Dx?

A

Obstruction

83
Q

Patient with LLQ abd pain, Fever, ↑wbc and Tender abdomen normal KUB, and mild divertulitis on CT. Tx?

A
  • Liquid diet

* Oral Cipro + mtz

84
Q

Patient with LLQ abd pain, Fever, ↑wbc and Tender abdomen normal KUB, and severe divertulitis on CT. Tx?

A
  • NPO

* IV ceftriaxone + mtz or Gent/ampicillin + mtz

85
Q

Patient with LLQ abd pain, Fever, ↑wbc and Tender abdomen normal KUB, and diverticular abscess on CT. Tx?

A
  • NPO
  • IV ceftriaxone + mtz or Gent/ampicillin + mtz
  • Drainage
86
Q

3 most common cancers?

A

lung>breast>colon

87
Q

2nd most common cause of cancer death?

A

Colon cancer

88
Q

Patient > 50, smoker, consumes alcohol, ↑BMI with iron defficiency anemia. Possible dx and next step?

A

Colon cancer

Next step: Colonoscopy + Bx

89
Q

Thin stool, alternate bowel habits (constipation-diarrhea-constipation-diarrhea), obstruction, hematochezia. Possible dx and next step?

A

Colon cancer

Next step: Colonoscopy + Bx

90
Q

Colon cancer screening guidelines?

A

Start screening at 50 (or before if high-risk) with:
• FOBT q2yr until 75-85 (depending on 10-yr risk)
• Flexible sigmoidoscopy q10 yr until 75-85(depending on 10-yr risk)

91
Q

Treatment of colon cancer?

A
  • Resection
  • Stage Chest, abd, pelvis CT
  • If extracolonic involvement–> chemo with (FOLFOX or FOLFIRI) + Bevacizumab
92
Q

Types of colon polyps and frequency of follow-up.

A

Low risk: Tubular, pedunculated, < 2 cm. Colonoscopy q5-10yr

High risk: Sessile, villous, > 2 cm. Colonoscopy q1-3yr

93
Q

Patient with 1000 polyps at 18 years of age. Dx a treatment

A

Familial adenomatous polyposis.

Tx: with prophilactic colectomy because of risk of cancer by age of 40 and death by 50

94
Q

Family with 3 member with colon, endometrial or ovarian cancer, in 2 generations, one under 50. Dx?

A

Hereditary nonpolyposis colorectal cancer (Lynch syndrome)

95
Q

Colon cancer + brain tumor. Dx?

96
Q

Colon cancer + jaw tumor. Dx?

97
Q

Patient with benign polyps, hyperpigmented buccal mucosa and small intestine hamartomas. Dx?

A

Peutz-Jeghers

98
Q

25-yo patient with bloody diarrhea, whose colonoscopy shows continuous inflammatory lesions that start in the rectum. EGD is normal. A bx of lessions is taken which shows superficial inflammation and crypt abscesses. Dx?

A

Ulcerative colitis

99
Q

55-yo patient with a history of several months of watery diarrhea, weight loss, Iron def, osteopenia, and B12 def.,. Colonoscopy and EGD show skip lesions at several parts of the GI tract. Bx of lesion shows transmural inflammation and noncaseating granulomas. Dx?

A

Chron’s disease

100
Q

Which IBD has increased risk of colon cancer? How should be the screening?

A

Ulcerative colitis

  • Screening: Colonoscopy 8 yrs after Dx, then q1yr
101
Q

Primary sclerosis cholangitis, p-ANCA, Erythema nodosum are related with wich IBD?

A

Ulcerative colitis

102
Q

Fistulas (entero-cutaneous, entero-vaginal, entero-vesicular, entero-entero) and nutritional deficiencies are related with wich IBD?

A

Chron’s disease

103
Q

Management of IBD flares?

A

Roule out infections (C. Diff).

Oral prednisone and antibiotics if infection.

104
Q

Tx for mild Ulcerative colitis?

A

5-ASA compounds: mesalamine, sulfasalazine

105
Q

Tx for moderate Ulcerative colitis?

A

Oral prednisone for flares, then immunomodulators (azathioprine, 6-mercaptopurine)

106
Q

Tx for severe Ulcerative colitis?

A

IV steroids for flares, then infliximab or Cyclosporine.

107
Q

Tx for mild Chron’s disease?

A

5-ASA compounds (mesalamine, sulfasalazine) can be used but are less effective

108
Q

Tx for moderate Chron’s disease?

A

Oral prednisone for flares, then immunomodulators (azathioprine, 6-mercaptopurine)

109
Q

Tx for severe Chron’s disease?

A

IV steroids for flares, then infliximab.

110
Q

Role of surgery in Ulcerative colitis?

A

Colectomy is curative

111
Q

Role of surgery in Chron’s disease?

A

Fistulectomy, drain abscesses

112
Q

Patient with chorea, Cirrhosis, Kaiser-Fleischer rings. Dx, next step, and tx?

A

WILSON’S

Next step:
Ceruloplasmin
Urinary copper
Best test: Bx (↑Copper)

Tx:
Penicillamine
Transplant

113
Q

Hyperpigmented skin, DM, cirrhosis, Diastolic CHF. Dx, next step, and tx?

A

HEMOCHROMATOSIS

Next step:
1st: Ferritin > 1000
Transferrin saturation > 50%
Best test: Bx (↑Fe)

Tx: Phlebotomy
Deferoxamine

114
Q

Young patient with COPD, small smoking history + cirrhosis. Dx, next step, and tx?

A

A1-ANTITRIPSIN DEFICIENCY

Next step:
Bx: PAS (+) macrophages

Tx:
Transplant

115
Q

Man, 40yo, pruritis, jaundice, IBD (ulcerative colitis). Dx, next step, and tx?

A

PRIMARY SCLEROSING CHOLANGITIS (Autoimmune disease; Fibrosis of extrahepatic ducts)

Next step:
Magnetic resonance cholangiopancreatography (MRCP): “beads on a string” pattern (pathognomonic)
ERCP to get Bx: onion skin fibrosis

Tx:
Transplant
Ursodeoxycholic acid while waiting for transplant

116
Q

Women, 40yo, pruritis, jaundice, NO association with IBD. Dx, next step, and tx?

A

PRIMARY BILIARY CIRRHOSIS (Autoimmune disease; Fibrosis of intrahepatic ducts)

Next step:
AMA
Magnetic resonance cholangiopancreatography (MRCP): Normal
Dx test: Bx

Tx:
Transplant

117
Q

Jaundice, gynecomastia, palmar erythema, spider angiomas, ascites, varices.

Labs: AST and ALT are normal, ↑INR, Thrombocytopenia

Dx?

118
Q

Confused , Altered mental status, Asterixis, Cirrhosis. Dx, next step, and tx?

A

Hepatic encephalopathy

Dx: clinical. No next step needed

Tx:

  • Lactulose
  • Rifaximin
  • Zinc
119
Q

Tx of Esophageal varices?

A
  • Acute setting: band, Ceftriaxone (prevent Spontaneous bacterial peritonitis and octreotide (↓ portal pressure)
  • Nadalol or propranolol
  • TIPS (bypass of the liver but may induce hepatic encephalopathy
120
Q

Bulging flancs, shifting dullness, fluid wave. Dx, next step and tx?

A

Ascites

Next step:
- Paracentesis + Bx
- Get serum-ascites albumin gradient (SAAG)= Serum albumin – fluid albumin
• > 1.1: Cirrhosis or right-sided heart failure
• < 1.1: Tb or cancer (ovarian, pancreatic)

Tx: furosemide + spironolactone, fluid restriction, therapeutic paracentesis

121
Q

Patient with history of cirrhosis, fever and abdominal pain. Dx, next step, tx?

A

Spontaneous bacterial peritonitis

Next step:

  • Paracentesis showing neutrophils > 250
  • Culture generally comes back negative

Tx: ceftriaxone
F/U: Total protein of fluid < 1 –> prophylaxis with fluoroquinolone (norfloxacine or ciprofloxacine)

122
Q

Causes of Hepatocellular carcinoma:

A
  • Cirrhosis

- Hepatitis B

123
Q

Screening for Hepatocellular carcinoma

A
  • Screen: RUQ U/S + AFP

- Confirmatory test: triple phase CT

124
Q

cirrhotic patient, hematemesis. Dx, next steps, Tx?

A

Esophageal varices

Next steps:

  • 2 large bore IV >18G
  • IVF
  • IV PPI
  • Type and cross
  • Call GI to get EGD
  • octreotide + ceftriaxone

Tx:

  • Balloon, band
  • TIPS (bypass of the liver but may induce hepatic encephalopathy

Prophylaxis: Nadalol or propranolol

125
Q

Patient with history of Dyspepsia, H. Pylori, NASAIDs, hematemesis. Dx, next steps, Tx?

A

Peptic ulcer disease

Next steps and Tx:

  • 2 large bore IV >18G
  • IVF
  • IV PPI
  • Type and cross
  • Call GI to get EGD
126
Q

College student, who went to a wild party, drank a lot and now has hematemesis. Dx, next steps, Tx?

A

Mallory-Weiss

Next steps and Tx:

  • 2 large bore IV >18G
  • IVF
  • IV PPI
  • Type and cross
  • Call GI to get EGD

Tx: Supportive tx because it’s self-limited

127
Q

bulimic patient, Fever, dyspnea, hypotensive, hematemesis. Rx shows pneumomediastinum. Dx, next steps, Tx?

A

Boerhaave (transmural tear of esophagus)

Next steps:
- 2 large bore IV >18G, IVF, IV PPI, Type and cross
•	1st: Gastrografin swallow
•	2nd: Barium
•	Last: EGD (if previous are normal)

Tx: Surgery

128
Q

Patient with painless hematemesis. Dx, next steps, Tx?

A

Dieulafoy’s lesion

Next steps:

  • 2 large bore IV >18G, IVF, IV PPI, Type and cross
  • Call GI to get EGD

Tx: Resect superficial artery (anatomic variant)

129
Q

Patient with constipation, blood on toilet paper and in the stool. Dx?

A

Internal hemorrhoids

130
Q

White caucasian male, > 50 y-o, with painless blight red blood per rectum. Dx, next steps, Tx?

A

Diverticular hemorrhage

Next steps:

  • 2 large bore IV >18G, IVF, IV PPI, Type and cross
  • Call GI to get EGD and Colonoscopy

Tx: hemicolectomy

131
Q

Patient with Atherosclerosis, AFib, abdominal pain out of proportion of physical exam, weight loss, and hematoquezia. Dx, next steps, Tx?

A

Mesenteric ischemia

Next steps:

  • 2 large bore IV >18G, IVF, IV PPI, Type and cross
  • Angiogram

Tx: Resect death tissue or revascularize

132
Q

Patient hypotensive, painful blight red blood per rectum. Dx, next steps, Tx?

A

Ischemic colitis

Next steps:

  • 2 large bore IV >18G, IVF, IV PPI, Type and cross
  • Colonoscopy

Tx: Supportive

133
Q

Patient with epigastric abd pain that radiates to the back, N/V, and anorexia. on physical, Cullen sign, turner sign (hematomas in abd wall). Lipase > 3 times upper limit. What are posible etiologies of this disease?

A
  • EtOH
  • Gallstones
  • Meds (HAART)
  • Hypertriglyceridemia
  • ERCP
134
Q

Patient with epigastric abd pain that radiates to the back, N/V, and anorexia. on physical, Cullen sign, turner sign (hematomas in abd wall). Lipase > 3 times upper limit. Dx, next step, and tx?

A

Pancreatitis

Next steps:

  • US: nor for Dx but to know etiology (gall stones)
  • MRCP: nor for Dx but to know etiology
  • NPO
  • IVF
  • Analgesia
  • Refeed on demand
  • ERCP when gall stone eitology and stone still there (dilated ducts on US and elevated bilirrubins)
135
Q

Best test to Dx pancreatitis?

A

Lipase > 3 times upper limit

136
Q

Best test to determine prognosis on pancreatitis?

137
Q

Early complications of pancreatitis

A

ARDS
HypoCa (Dx with ionized calcium)
Pleural effusion (don’t tap unless infected)
Ascitis (don’t tap unless infected)

138
Q

Patient with pancreatitis and SIRS on day 7. Dx, next step and tx?

A

Infection

Next step: CT scan, Bx, and culture

Tx: Meropenem initially, then whatever the culture tells

139
Q

When is used CT scan for pancreatitis?

A

CT scan only if labs are normal but clinically you think is pancreatitis or for complications (abscess or pseudocyst)

140
Q

Tx of pseudocyst as complication of pancreatitis?

A

Rule of 6

If < 6 cm and < 6 weeks: watch and wait
if > 6 cm and > 6 weeks: drain and Abx

141
Q

Patient who gets jaundice under stress, normal urine. Dx?

A

Gilbert’s (unconjugated hyperbilirrubinemia)

*Can’t be Crigler-Najjar because it is a severe version that produces perinatal death

142
Q

Patient who gets jaundice under stress, dark urine. Dx?

A

Dublin-Johnson or Rotor (conjugated hyperbilirubinemia)

*The only what to differentiate is by directly visualizing the liver. If it’s dark, then it’s Dublin-Jonson

143
Q

Route of infection of HBV?

A

PWID, sex, vertical

144
Q

Is HBV acute or chronic?

A

“Hepatitis B is hepatitis both”
Immunocompetent patient: acute infection because s/he clears the virus
Immunocompromised patient: chronic infection because s/he can’t clear the virus

145
Q

Meaning of HBsAg:

A

Currently infected

146
Q

Meaning of HBeAg:

A

infectious

147
Q

Meaning of IgM-HBsAg:

A

early infection

148
Q

Meaning of IgG-HBsAg:

A

immune (either through vaccination or previous exposure)

149
Q

Meaning of IgG-HBcAg:

A

immune through exposure

150
Q

Route of infection of HCV?

A

PWID, blood transfusions, sex (?)

151
Q 
HCV Ab (+)
HCV RNA (+)
Dx?
A

Chronic infection of HCV

152
Q 
HCV Ab (-)
HCV RNA (+)
Dx?
A

Recently infected with HCV

153
Q 
HCV Ab (+)
HCV RNA (-)
Dx?
A

Treated or cleared HCV

154
Q

Route of infection of HDV?

A

PWID, sex, but REQUIRES HBV, hence happens in immunocompromised patients

155
Q

Third-world country, pregnant woman with hepatitis. What type of hepatitis?

A

Hepatitis E (fecal-oral transmision)

156
Q

A patient presents with sudden onset of severe, diffuse abdominal pain. Exam reveals peritoneal signs, and AXR reveals free air under the diaphragm. Management?

A

Emergent laparotomy to repair perforated viscus.

157
Q

The most likely cause of acute lower GI bleed in patients > 40 years of age.

A

Diverticulosis.

158
Q

Diagnostic modality used when ultrasound is equivocal for cholecystitis.

A

HIDA scan.

159
Q

Risk factors for cholelithiasis.

A

Fat, female, fertile, forty, fl atulent.

160
Q

Inspiratory arrest during palpation of the RUQ.

A

Murphy’s sign, seen in acute cholecystitis.

161
Q

The most common cause of small bowel obstruction (SBO) in patients with no history of abdominal surgery.

162
Q

The most common cause of small bowel obstruction (SBO) in patients with a history of abdominal surgery.

A

Adhesions.

163
Q

Identify key organisms causing diarrhea:

Most common organism

A

Campylobacter

164
Q

Identify key organisms causing diarrhea:

Recent antibiotic use

A

Clostridium difficile

165
Q

Identify key organisms causing diarrhea:

Camping

166
Q

Identify key organisms causing diarrhea:

Traveler’s diarrhea

167
Q

Identify key organisms causing diarrhea:

Church picnics/mayonnaise

168
Q

Identify key organisms causing diarrhea:

Uncooked hamburgers

A

E. coli O157:H7

169
Q

Identify key organisms causing diarrhea:

Fried rice

A

Bacillus cereus

170
Q

Identify key organisms causing diarrhea:

Poultry/eggs

A

Salmonella

171
Q

Identify key organisms causing diarrhea:

Raw seafood

A

Vibrio, HAV

172
Q

Identify key organisms causing diarrhea:

AIDS

A

Isospora, Cryptosporidium, Mycobacterium avium complex (MAC)

173
Q

Identify key organisms causing diarrhea:

Pseudoappendicitis

174
Q

A 25-year-old Jewish man presents with pain and watery diarrhea after meals. Exam shows fistulas between the bowel and skin and nodular lesions on his tibias.

A

Crohn’s disease.

175
Q

Inflammatory disease of the colon with ↑ risk of colon cancer.

A

Ulcerative colitis (greater risk than Crohn’s).

176
Q

Extraintestinal manifestations of IBD.

A

Uveitis, ankylosing spondylitis, pyoderma gangrenosum,

erythema nodosum, 1° sclerosing cholangitis.

177
Q

Medical treatment for IBD.

A

5-ASA agents and steroids during acute exacerbations.

178
Q

Difference between Mallory-Weiss and Boerhaave tears.

A

Mallory-Weiss—superficial tear in the esophageal mucosa;

Boerhaave—full-thickness esophageal rupture.

179
Q

Charcot’s triad.

A

RUQ pain, jaundice, and fever/chills in the setting of

ascending cholangitis.

180
Q

Reynolds’ pentad.

A

Charcot’s triad plus shock and mental status changes, with suppurative ascending cholangitis.

181
Q

Medical treatment for hepatic encephalopathy.

A

↓ protein intake, lactulose, rifaximin.

182
Q

First step in the management of a patient with an acute GI bleed.

A

Establish the ABCs.

183
Q

A four-year-old child presents with oliguria, petechiae, and jaundice following an illness with bloody diarrhea. Most likely diagnosis and cause?

A

Hemolytic-uremic syndrome (HUS) due to EHEC (Enterohemorrhagic E. coli) 0157:H7

184
Q

Post-HBV exposure treatment.

A

HBV immunoglobulin.

185
Q

Classic causes of drug-induced hepatitis.

A 
TB medications (INH, rifampin, pyrazinamide),
acetaminophen, and tetracycline.
186
Q

40-year-old obese woman with elevated alkaline
phosphatase, elevated bilirubin, pruritus, dark urine, and
clay-colored stools.

A

Biliary tract obstruction.

187
Q

Hernia with highest risk of incarceration—indirect, direct, or femoral?

A

Femoral hernia.

188
Q

A 50-year-old man with a history of alcohol abuse presents with boring epigastric pain that radiates to the back and is relieved by sitting forward. Management?

A

Confirm the diagnosis of acute pancreatitis with elevated amylase and lipase. Make the patient NPO and give IV fluids, O2, analgesia, and “tincture of time.”

MCCQE1 (19 decks)

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