Gastroenterology Flashcards
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?
Cholelithiasis
Next step: RUQ U/S (which would show gallstone)
Tx:
- Elective cholecystectomy
- If non-surgical candidate –> ursodeoxycholic acid
Patient with constant RUQ pain, (+) murphy sign, mild leucocytosis. Dx, next step and tx?
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
Painful jaundice, murphy sign, mild leucocytosis, ↑AST, ↑ALT, ↑amylase. Dx, next step and tx?
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
RUQ pain, fever, jaundice. Dx, next step and tx?
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
Charcot triad?
RUQ pain
Fever
Jaundice
Dx: Cholangitis
Reynolds pentad?
RUQ pain
Fever
Jaundice
Hypotension
Altered mental status
Dx: Severe cholangitis
Can pip/tazo be used for gallbladder deases?
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)
Odynophagia, dysphagia + history of taking NSAIDS, Antibiotics (tetracyclins), Biphosphonades, or HAART. Dx, next step and treatment?
Pill induced esophagitis
Next step: EGD + Bx
Tx: Remove medication, time to heal, PPI
Odynophagia, dysphagia, oral thrush. Dx, next step and treatment?
Infectious esophagitis (Candida)
Next step: EGD + Bx
Tx: fluconazole or nystatin oral suspension
Odynophagia, dysphagia, oral vesicles on erythematous base in multiple stages of healing . Dx, next step and treatment?
Infectious esophagitis (HSV)
Next step: EGD + Bx
Tx: Valacyclovir or acyclovir
Odynophagia, dysphagia, CMV on EGD Bx. Treatment?
valganciclovir
Patient with history of Asthma, seasonal Allergies, Atopy (eczema) + Odynophagia, dysphagia. Dx, next step and treatment?
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
Kid who by accident drink drain cleaner, hoorse or stridor (larynx burn), Drooling. Dx and next step?
Caustic esophagitis
Next step: Intubate!!! then EGD + Bx to determine the severity
Adult in a suicide attempt who drank drain cleaner, hoorse, drooling. Dx and next step?
Caustic esophagitis
Next step: Intubate!!! then EGD + Bx to determine the severity
Low severity caustic esophagitis management?
In early stages, NGT and lavage
Low severity: liquid diet
NEVER NEUTRALIZE THE pH
NEVER INDUSE EMESIS
High severity caustic esophagitis management?
In early stages, NGT and lavage
High severity: NPO x 72 hours and then repeat EGD
NEVER NEUTRALIZE THE pH
NEVER INDUSE EMESIS
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?
Achalasia
Next step: EDG + Bx
Tx: Myotomy is the election tx
- Botulinum toxin only when non-surgical candidate
Follow up: treat iatrogenic GERD
Woman, Dysphagia for solids and liquids, Calcinosis, Reynold’s, Sclerodactyly, Telangiectasia, GERD.
Dx, next step, tx?
Scleroderma
Next steps:
- barium sallow–> LES wide open
- manometry –> No esophageal activity
- EGD + Bx
Tx: PPI
Patient with recurrent episodes of crushing retrosternal chest pain that betters with Nitroglycerin and CCB. Enzimes are always negative.
Dx, next step, tx?
Diffuse esophageal spasm
Next steps:
- Barium sallow–> Corkscrew esophagus
- Manometry–> diffuse uncoordinated contractions
- EGD + Bx
Tx:
• CCB
• Nitrates PRN
Patient with intermitent disphagia of solid food (big bites).
Dx, next step, tx?
Schatzki’s Ring
Next steps:
- Barium sallow-> narrow lumen
- EGD + Bx-> rule out cancer and shows the ring
Tx: Lyse the ring during EGD
Woman, Dysphagia for solids then liquids, Iron deficiency anemia.
Dx, next step, tx?
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
Old man, Halitosis, Regurgitation of undigested food, Dysphagia for solids then liquids.
Dx, next step, tx?
Zenker’s diverticulum
Next step:
- Barrium sallow
- EGD + Bx
Tx: Surgery
Long-lasting GERD, Progressive dysphagia, Weight loss
Barrium sallow–> symetric/circumferential loss of lumen
Dx and tx?
Stricture
Tx:
- High-dose PPI
- Dilation
Long-lasting GERD, Progressive dysphagia, Weight loss
Barrium sallow–> asymmetric loss of lumen
Dx?
Esophagus Adenocarcinoma
Patient with a history of alcohol consumption, a heavy smoker, Progressive dysphagia, Weight loss
Barrium sallow–> asymmetric loss of lumen
Dx?
Squamous cell carcinoma
Patient with Nocturnal asthma symptoms that are absent during day, coughing and hoarseness. Dx and next step?
GERD
Next step: PPI + lifestyle changes x 6 weeks
Patient with Burning chest pain, Worsens laying down and with spicy food, Nausea, Vomiting, Macrocytic Anemia, and Weight loss. Dx and next step?
GERD with alarm symptoms
Next step: EGD + Bx
GERD on EGD. Tx?
PPI
Intestinal metaplasia (Bartlett’s) on EGD. Tx?
↑PPI (BID) + Annual EGD
Dysplasia on EGD. Tx?
local ablation +PPI + annual EGD
Adenocarcinoma on EGD. Tx?
Resection/chemo + radiation
Patient with GERD who doesn’t tolerate PPI. Next step?
Surgery (Nissen fundoplication)
Patient with gnawing epigastralgia.
EGD: Single large ulcer on duodenum. Possible dx?
H. Pylori
Patient with gnawing epigastralgia.
EGD: Multiple shallow ulcers.
Possible dx?
NSAIDs
Patient with gnawing epigastralgia.
EGD: ulcers with necrotic base heaped margings
Possible dx?
Malignancy
Patient with gnawing epigastralgia and diarrhea.
EGD: Multiple refractory ulcers
Possible dx?
Gastrinoma/Zollinger-Ellison
Patient with dyspepsia and PUD. Never treated before for H. Pylori.
Best dx test?
Serology
Because never treated before and currently having Sx. If positive, treat immediately
Patient with dyspepsia and PUD. Treated before for H. Pylori.
Best dx test?
EGD + Bx (histology)
Not urease test. Histology it’s better
Patient who has finished treatment for H. Pylori. Test to confirm erradication?
Stool Ag
Treatment for H. Pylori?
Triple therapy
- Clarithromycin
- Amoxicillin (or metronidazole if allergic)
- PPI
Patient with refractory gastric ulcers and diarrhea.
Dx, next steps, tx?
Gastrinoma/Zollinger-Ellison
Next steps:
1. Gastrin level > 1600 (normal < 250)
•Between 250 and 2600, do a Secretin stimulation test
- Localize the tumor with an Somatostatin receptor Scintigraphy (SRS) (AKA, Octreotide scan)
Tx: resection
Complication of Gastrinoma/Zollinger-Ellison
Gastric malignancy
Diabetic patient with chronic nausea and vomiting, abdominal pain when eating and peripheral neuropathy. Dx, next step, tx?
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
Tx of gastroparesis
Low fiver, small volume meal Avoid opiates, anticholinergics Manage blood glucose Prokinetic agents • Metoclopramide PO in chronic management • Erythromycin IV in acute management
Marihuana smoker with nausea and vomiting that last a few days, then disapears and then come again. Dx and tx?
Cyclic vomiting syndrome
Tx:
- Stop THC
- Metoclopramide or Erythromycin
Patient with early satiety, weight loss, nausea and vomiting. Dx, next step?
Gastric carcinoma
Next steps:
- EGD + Bx
- PET scan to stage
What is a MATLoma and tx?
Gastric lymphoma produced by H. Pylori. Treated with triple therapy: Clarithromycin, Amoxicillin (or metronidazole if allergic), and PPI
Watery diarrhea, 3rd world country, no boiling water. Likely cause of diarrhea?
Vibrio cholera
Patient who comes from a trip to central america and has watery diarrhea. Likely cause of diarrhea?
ETEC (Enterotoxigenic E. Coli)
Patient with watery diarrhea who was on a picnic, he ate egg salad and potato salad. Likely cause of diarrhea?
S. Aureus
Patient with watery diarrhea who ate at a Chinese buffet and ate reheated rice. Likely cause of diarrhea?
Bacillus cereus
Patient how was hiking and drank fresh water. Now has watery diarrhea. Likely cause of diarrhea?
Giardia
Patient with diarrhea, fever and abd pain. Ate raw chicken. Likely cause of diarrhea?
Salmonella
Patient with bloody diarrhea, fever and abd pain. Likely cause of diarrhea?
Entamoeba histolyctica
Patient with HIV/AIDS and diarrhea. Likely cause of diarrhea?
Cryptosporidium
What is the most common cause of bloody diarrhea ?
Campylobacter
Red flags in diarrhea?
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
Patient with bloody diarrhea, Fever, Severe dehydration,
Duration of more than 3 day, and Severe abdominal pain. Next step?
C. diff NAAT
Fecal leukocytes
Fecal occult blood
Ova + Parasites
Stable hospitalized patient witn watery smelly diarrhea. Dx, next step and tx?
C. Difficile
Next step: C. diff NAAT
Tx:
- Stop culprit ab
- IV fluids
- Vacomycin or fidaxomicin (MTZ only if these meds are not available)
Hospitalized patient witn watery smelly diarrhea, hypotensive, toxic megacolon, paralytic ileus, or an elevated lactate. Dx, next step and tx?
C. Difficile
Next step: C. diff NAAT
Tx:
- Stop culprit ab
- IV fluids
- ↑PO (or PR) Vancomycin + IV MTZ
Patient with bloody diarrhea, who a week after is pale, and has edema. • Petechiae and HTN on physical exam.
Dx, next step, and tx?
Hemolytic uremic syndrome
Next step:
- CBC
- Blood smear to confirm hemolytic anemia
- Renal function, uroanalysis
- Shigella toxic assay
Tx:
- Supportive
- Plasma exchange
Patient with diarrhea of > 4 weeks of duration. First differentials to think of?
Medications
Laxatives
Lactose deficency
C. Diff chronic infection
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?
Secretory
Differential:
- VIPoma
- Gastrinoma
- Carcinoid
- C- Diff
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?
Osmotic
Differential:
- Celiac
- Lactose def
- Malabsoption
Patient with diarrhea of > 4 weeks of duration.
Fecal WBC (+)
Fecal RBC (+)
Mucus (+)
Type of diarrhea and differential?
Inflammatory
DIfferential:
- Chron’s
- Ulcerative colitis
- Radiation colitis
- Diverticulosis
Patient with right-sided heart fibrosis, flushing, and chronich diarrhea. Dx and next step?
Carcinoid (Tumor in the liver that secretes serotonin into the portal veins)
Next step: Urinary 5 HIAA (metabolite of serotonin)
Folate. Place of absorption and sx of deficiency?
Duodenum
megaloblastic anemia
Iron. Place of absorption and sx of deficiency?
Duodenum
microcytic anemia
Calcium. Place of absorption and sx of deficiency?
Duodenum
osteoporosis
Vit A. Place of absorption and sx of deficiency?
Terminal ileum
night blindness
Vit D. Place of absorption and sx of deficiency?
Terminal ileum
osteoporosis
Vit E. Place of absorption and sx of deficiency?
Terminal ileum
nystagmus
Vit K. Place of absorption and sx of deficiency?
Terminal ileum
bleeding
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?
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)
Diarrhea, Flatulence, Distension, No weight loss. Dx?
Lactose intolerance
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?
Tropical sprue
Diarrhea, distension, Ataxia, memory loss, seizures, Joint pain, Lymphadenopathy. Dx, next step and tx?
Whipple’s disease
Next step:
- EGD + Bx: Pas (+) macrophages
Tx: Tmx-smp or doxycycline
Western patient over 50, constipation. Diverticulosis on colonoscopy. Tx?
High-fiber diet rich in fruits and vegetables
Patient over 50 with postprandial LLQ abdominal pain that is relieved with bowel movement. Dx and tx?
Symptomatic, uncomplicated diverticulosis/ Diverticular spams
Tx: High-fiber diet rich in fruits and vegetables
Patient with LLQ abd pain, Fever, ↑wbc and Tender abdomen. Dx and next steps?
Diverticulitis
Next steps:
- Upright KUB to r/u perforation
- CT scan of abdomen with IV contrasts to determine the severity
Patient with LLQ abd pain, Fever, ↑wbc and Tender abdomen and free air on KUB. Dx and tx?
Perforated diverticulitis
- Surgery
- IV Cipro + mtz or Gent/ampicillin + mtz
Patient with LLQ abd pain, Fever, ↑wbc and Tender abdomen and air-fluid levels on KUB. Dx?
Obstruction
Patient with LLQ abd pain, Fever, ↑wbc and Tender abdomen normal KUB, and mild divertulitis on CT. Tx?
- Liquid diet
* Oral Cipro + mtz
Patient with LLQ abd pain, Fever, ↑wbc and Tender abdomen normal KUB, and severe divertulitis on CT. Tx?
- NPO
* IV ceftriaxone + mtz or Gent/ampicillin + mtz
Patient with LLQ abd pain, Fever, ↑wbc and Tender abdomen normal KUB, and diverticular abscess on CT. Tx?
- NPO
- IV ceftriaxone + mtz or Gent/ampicillin + mtz
- Drainage
3 most common cancers?
lung>breast>colon
2nd most common cause of cancer death?
Colon cancer
Patient > 50, smoker, consumes alcohol, ↑BMI with iron defficiency anemia. Possible dx and next step?
Colon cancer
Next step: Colonoscopy + Bx
Thin stool, alternate bowel habits (constipation-diarrhea-constipation-diarrhea), obstruction, hematochezia. Possible dx and next step?
Colon cancer
Next step: Colonoscopy + Bx
Colon cancer screening guidelines?
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)
Treatment of colon cancer?
- Resection
- Stage Chest, abd, pelvis CT
- If extracolonic involvement–> chemo with (FOLFOX or FOLFIRI) + Bevacizumab
Types of colon polyps and frequency of follow-up.
Low risk: Tubular, pedunculated, < 2 cm. Colonoscopy q5-10yr
High risk: Sessile, villous, > 2 cm. Colonoscopy q1-3yr
Patient with 1000 polyps at 18 years of age. Dx a treatment
Familial adenomatous polyposis.
Tx: with prophilactic colectomy because of risk of cancer by age of 40 and death by 50
Family with 3 member with colon, endometrial or ovarian cancer, in 2 generations, one under 50. Dx?
Hereditary nonpolyposis colorectal cancer (Lynch syndrome)
Colon cancer + brain tumor. Dx?
Turcot
Colon cancer + jaw tumor. Dx?
Gardner
Patient with benign polyps, hyperpigmented buccal mucosa and small intestine hamartomas. Dx?
Peutz-Jeghers
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?
Ulcerative colitis
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?
Chron’s disease
Which IBD has increased risk of colon cancer? How should be the screening?
Ulcerative colitis
- Screening: Colonoscopy 8 yrs after Dx, then q1yr
Primary sclerosis cholangitis, p-ANCA, Erythema nodosum are related with wich IBD?
Ulcerative colitis
Fistulas (entero-cutaneous, entero-vaginal, entero-vesicular, entero-entero) and nutritional deficiencies are related with wich IBD?
Chron’s disease
Management of IBD flares?
Roule out infections (C. Diff).
Oral prednisone and antibiotics if infection.
Tx for mild Ulcerative colitis?
5-ASA compounds: mesalamine, sulfasalazine
Tx for moderate Ulcerative colitis?
Oral prednisone for flares, then immunomodulators (azathioprine, 6-mercaptopurine)
Tx for severe Ulcerative colitis?
IV steroids for flares, then infliximab or Cyclosporine.
Tx for mild Chron’s disease?
5-ASA compounds (mesalamine, sulfasalazine) can be used but are less effective
Tx for moderate Chron’s disease?
Oral prednisone for flares, then immunomodulators (azathioprine, 6-mercaptopurine)
Tx for severe Chron’s disease?
IV steroids for flares, then infliximab.
Role of surgery in Ulcerative colitis?
Colectomy is curative
Role of surgery in Chron’s disease?
Fistulectomy, drain abscesses
Patient with chorea, Cirrhosis, Kaiser-Fleischer rings. Dx, next step, and tx?
WILSON’S
Next step:
Ceruloplasmin
Urinary copper
Best test: Bx (↑Copper)
Tx:
Penicillamine
Transplant
Hyperpigmented skin, DM, cirrhosis, Diastolic CHF. Dx, next step, and tx?
HEMOCHROMATOSIS
Next step:
1st: Ferritin > 1000
Transferrin saturation > 50%
Best test: Bx (↑Fe)
Tx: Phlebotomy
Deferoxamine
Young patient with COPD, small smoking history + cirrhosis. Dx, next step, and tx?
A1-ANTITRIPSIN DEFICIENCY
Next step:
Bx: PAS (+) macrophages
Tx:
Transplant
Man, 40yo, pruritis, jaundice, IBD (ulcerative colitis). Dx, next step, and tx?
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
Women, 40yo, pruritis, jaundice, NO association with IBD. Dx, next step, and tx?
PRIMARY BILIARY CIRRHOSIS (Autoimmune disease; Fibrosis of intrahepatic ducts)
Next step:
AMA
Magnetic resonance cholangiopancreatography (MRCP): Normal
Dx test: Bx
Tx:
Transplant
Jaundice, gynecomastia, palmar erythema, spider angiomas, ascites, varices.
Labs: AST and ALT are normal, ↑INR, Thrombocytopenia
Dx?
Cirrhosis
Confused , Altered mental status, Asterixis, Cirrhosis. Dx, next step, and tx?
Hepatic encephalopathy
Dx: clinical. No next step needed
Tx:
- Lactulose
- Rifaximin
- Zinc
Tx of Esophageal varices?
- 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
Bulging flancs, shifting dullness, fluid wave. Dx, next step and tx?
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
Patient with history of cirrhosis, fever and abdominal pain. Dx, next step, tx?
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)
Causes of Hepatocellular carcinoma:
- Cirrhosis
- Hepatitis B
Screening for Hepatocellular carcinoma
- Screen: RUQ U/S + AFP
- Confirmatory test: triple phase CT
cirrhotic patient, hematemesis. Dx, next steps, Tx?
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
Patient with history of Dyspepsia, H. Pylori, NASAIDs, hematemesis. Dx, next steps, Tx?
Peptic ulcer disease
Next steps and Tx:
- 2 large bore IV >18G
- IVF
- IV PPI
- Type and cross
- Call GI to get EGD
College student, who went to a wild party, drank a lot and now has hematemesis. Dx, next steps, Tx?
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
bulimic patient, Fever, dyspnea, hypotensive, hematemesis. Rx shows pneumomediastinum. Dx, next steps, Tx?
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
Patient with painless hematemesis. Dx, next steps, Tx?
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)
Patient with constipation, blood on toilet paper and in the stool. Dx?
Internal hemorrhoids
White caucasian male, > 50 y-o, with painless blight red blood per rectum. Dx, next steps, Tx?
Diverticular hemorrhage
Next steps:
- 2 large bore IV >18G, IVF, IV PPI, Type and cross
- Call GI to get EGD and Colonoscopy
Tx: hemicolectomy
Patient with Atherosclerosis, AFib, abdominal pain out of proportion of physical exam, weight loss, and hematoquezia. Dx, next steps, Tx?
Mesenteric ischemia
Next steps:
- 2 large bore IV >18G, IVF, IV PPI, Type and cross
- Angiogram
Tx: Resect death tissue or revascularize
Patient hypotensive, painful blight red blood per rectum. Dx, next steps, Tx?
Ischemic colitis
Next steps:
- 2 large bore IV >18G, IVF, IV PPI, Type and cross
- Colonoscopy
Tx: Supportive
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?
- EtOH
- Gallstones
- Meds (HAART)
- Hypertriglyceridemia
- ERCP
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?
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)
Best test to Dx pancreatitis?
Lipase > 3 times upper limit
Best test to determine prognosis on pancreatitis?
BUN
Early complications of pancreatitis
ARDS
HypoCa (Dx with ionized calcium)
Pleural effusion (don’t tap unless infected)
Ascitis (don’t tap unless infected)
Patient with pancreatitis and SIRS on day 7. Dx, next step and tx?
Infection
Next step: CT scan, Bx, and culture
Tx: Meropenem initially, then whatever the culture tells
When is used CT scan for pancreatitis?
CT scan only if labs are normal but clinically you think is pancreatitis or for complications (abscess or pseudocyst)
Tx of pseudocyst as complication of pancreatitis?
Rule of 6
If < 6 cm and < 6 weeks: watch and wait
if > 6 cm and > 6 weeks: drain and Abx
Patient who gets jaundice under stress, normal urine. Dx?
Gilbert’s (unconjugated hyperbilirrubinemia)
*Can’t be Crigler-Najjar because it is a severe version that produces perinatal death
Patient who gets jaundice under stress, dark urine. Dx?
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
Route of infection of HBV?
PWID, sex, vertical
Is HBV acute or chronic?
“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
Meaning of HBsAg:
Currently infected
Meaning of HBeAg:
infectious
Meaning of IgM-HBsAg:
early infection
Meaning of IgG-HBsAg:
immune (either through vaccination or previous exposure)
Meaning of IgG-HBcAg:
immune through exposure
Route of infection of HCV?
PWID, blood transfusions, sex (?)
HCV Ab (+) HCV RNA (+) Dx?
Chronic infection of HCV
HCV Ab (-) HCV RNA (+) Dx?
Recently infected with HCV
HCV Ab (+) HCV RNA (-) Dx?
Treated or cleared HCV
Route of infection of HDV?
PWID, sex, but REQUIRES HBV, hence happens in immunocompromised patients
Third-world country, pregnant woman with hepatitis. What type of hepatitis?
Hepatitis E (fecal-oral transmision)
A patient presents with sudden onset of severe, diffuse abdominal pain. Exam reveals peritoneal signs, and AXR reveals free air under the diaphragm. Management?
Emergent laparotomy to repair perforated viscus.
The most likely cause of acute lower GI bleed in patients > 40 years of age.
Diverticulosis.
Diagnostic modality used when ultrasound is equivocal for cholecystitis.
HIDA scan.
Risk factors for cholelithiasis.
Fat, female, fertile, forty, fl atulent.
Inspiratory arrest during palpation of the RUQ.
Murphy’s sign, seen in acute cholecystitis.
The most common cause of small bowel obstruction (SBO) in patients with no history of abdominal surgery.
Hernia.
The most common cause of small bowel obstruction (SBO) in patients with a history of abdominal surgery.
Adhesions.
Identify key organisms causing diarrhea:
Most common organism
Campylobacter
Identify key organisms causing diarrhea:
Recent antibiotic use
Clostridium difficile
Identify key organisms causing diarrhea:
Camping
Giardia
Identify key organisms causing diarrhea:
Traveler’s diarrhea
ETEC
Identify key organisms causing diarrhea:
Church picnics/mayonnaise
S. aureus
Identify key organisms causing diarrhea:
Uncooked hamburgers
E. coli O157:H7
Identify key organisms causing diarrhea:
Fried rice
Bacillus cereus
Identify key organisms causing diarrhea:
Poultry/eggs
Salmonella
Identify key organisms causing diarrhea:
Raw seafood
Vibrio, HAV
Identify key organisms causing diarrhea:
AIDS
Isospora, Cryptosporidium, Mycobacterium avium complex (MAC)
Identify key organisms causing diarrhea:
Pseudoappendicitis
Yersinia
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.
Crohn’s disease.
Inflammatory disease of the colon with ↑ risk of colon cancer.
Ulcerative colitis (greater risk than Crohn’s).
Extraintestinal manifestations of IBD.
Uveitis, ankylosing spondylitis, pyoderma gangrenosum,
erythema nodosum, 1° sclerosing cholangitis.
Medical treatment for IBD.
5-ASA agents and steroids during acute exacerbations.
Difference between Mallory-Weiss and Boerhaave tears.
Mallory-Weiss—superficial tear in the esophageal mucosa;
Boerhaave—full-thickness esophageal rupture.
Charcot’s triad.
RUQ pain, jaundice, and fever/chills in the setting of
ascending cholangitis.
Reynolds’ pentad.
Charcot’s triad plus shock and mental status changes, with suppurative ascending cholangitis.
Medical treatment for hepatic encephalopathy.
↓ protein intake, lactulose, rifaximin.
First step in the management of a patient with an acute GI bleed.
Establish the ABCs.
A four-year-old child presents with oliguria, petechiae, and jaundice following an illness with bloody diarrhea. Most likely diagnosis and cause?
Hemolytic-uremic syndrome (HUS) due to EHEC (Enterohemorrhagic E. coli) 0157:H7
Post-HBV exposure treatment.
HBV immunoglobulin.
Classic causes of drug-induced hepatitis.
TB medications (INH, rifampin, pyrazinamide), acetaminophen, and tetracycline.
40-year-old obese woman with elevated alkaline
phosphatase, elevated bilirubin, pruritus, dark urine, and
clay-colored stools.
Biliary tract obstruction.
Hernia with highest risk of incarceration—indirect, direct, or femoral?
Femoral hernia.
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?
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.”
