Gastroenterology Flashcards
When to EGD Barrett’s Patients
- EGD shows Barretts -> next EGD 1 year
- 1 year later repeat EGD no dysplasia (only metaplasia) -> EGD q3yr
- Low Grade dysplasia - EGD 6 months -> still low dysplasia -> q1yr
- Dysplasia->metaplasia -> q3yr
- High Grade Dysplasia -> Endoscopic RF Ablation
H Pylori Testing
- Non Endo - Ab test for dx only, Urea breath/Fecal antigen Dx AND f/u
- Endo - for culture, urease testing - GOLD STANDARD but expensive
Treatment H Pylori
- PAC x 14 days (PPI, Amox, Clarithro
2. MOC x 14 days (Metronidazole, omep, clarithro)
H Pylori Tx failure
- Quad Tx - Tetra, metronidaz, bismuth, PPI
DO NOT REPEAT triple therapy with same abx (high clarithro resistance rates)
Who to test for H pylori
45yo M with abd pain and PUD
Are steroids ulcerogenic
NO but with NSAIDS increase bleeding by 10x
Dysphasia solids AND liquids with CP
Diffuse Esophageal spasm/corkscrew esophagus–>barium swallow–>manometric study (non-perstaltic rxn–>PPI (if no response CCB)
First bite dysphagia (intermittent)
Schatzki ring/esophageal strictures -> Pneumatic dilation
Food Regurg hours after, dyphagia solids and liquids
Barium swallow -> Birdsbeak -> Achalaisa-> EGD r/o secondary acalasia (cancer) -> surgical myotomy
Food impaction several times, EGD concentric rings, h/o allergies
Eosinophillic esophagitis -> PPI then aerosolized steroid (fluticasone/budesonide) then if refractory EGD dilation
Dysphagia with osteoporosis, acrne on tetracycline erythromcin
Pill esophagitis -> EGD
regurigating food from days ago, halotosis
zenker’s diverticulum
HIV with oral thrush
empiric fluconazole/itraconazole -> if no response -> EGD r/o CMV/herpes
Long standing heartburn with progressive dysphagia solids
Peptic stricture
Heartburn not relieved with antacids
trial of PPI -> if doesn’t work EGD -> if EGD no esophagitis -> ambulatory pH monitoring to prove GERD
Heartburn no response to PPI + weight loss
EGD
Can PPI/fundoplication reverse barretts
NO
PUD Tx
H2 blocker, PPI, sucralafte (cover ulcer)
Zollinger Ellison
MC radiographic finding=single duodenal ulcer Pancrease or duodenal tumors 2/3 tumors are malignant 1/4 a/w MEN I Serum fasting gastrin >1000, low pH dx
How long to monitor acute GI bleed after EGD
72 hours
High risk bleed
Visible vessel Adherent clot Ulcer >2cm Variceal bleeding Arterial Bleed
Prevent rebleed PUD
PPI
Cirrhosis with spider angiomata
Screening EGD, PPI (propranolol, nadolol) non selective (if asthma - no beta blocker - band ligation)
Only H Pylori test NOT affected by PPI use or GI bleed.
H Pylori SEROLOGY
Dilation of bile duct without evidence of obstruction
Biliary cyst
Primary Biliary Cirrhosis
Disease of microcopic bile ducts, no extrahepatic duct dilation -> jaundice, liver inflamm, liver failure
NEVER ACUTE liver failure (progressive)
Elevated alk phos from bile duct inflamm
Dx: Cholestatic LFT profile, serum anti Mitox Ab
Tx: Ursodeoxycholic Acid
Monitor: serial LFT’s
Fulminant Hepatic Failure
within 1 week, hepatic encephalopathy, jaundice without pre-existing liver dz,
Pancreatic CA dx
Older pt with painless jaundice, focal cutoff of bile duct on CT (without mass lesion seen) -> use EUS (better sensitivity for tumors AND can biopsy)
Large Esophageal varices
Non-selective beta blockers OR endoscopic LIGATION (not sclerotherapy) -> if refractory then TIPS
Erythema Nodosum
2/2 infections, drugs, systemic (inflamm) dz’s -> treat underlying d/o (IF NO underlying d/o, tx with corticosteroids or immunomodulators)
Colonoscopy Surveillence
If complete resection -> surveillence in 1 year
If incomplete resection -> surveillence in 3-6 months after surgery then again in 1 year
Gallbladder polyps
10mm - cholecystectomy (high potential for malignancy) (or if gallstones >3cm, calcified GB)
Oropharyngeal Dysphagia (difficulty swallowing)
Video fluoroscopy - chocking, coughing, h/o asp PNA, (ALS)
Acute Acalculous Cholecystitis
BEST test = Abd US -> CT doesn’t show GB wall thickening -> needs cholecystectomy (if not perc cholecystomy tube)
Celiac Dz
Anti TTG best test, don’t check anti-gliadin Ab
Wilson’s Dz
Young patient with acute liver failure, high retic ct, large fraction unconjugated bilirubin, low alk phos (
Acute Cholangitis
bacterial infection of biliary tree in obstructed system (high alk phos)
Charcot’s Trial: fever, jaundice, RUQ pain
Reynauds pentad: add confusion, septic shock
Start Abx -> ERCP for biliary decompression/stenting and stone removal if needed
Acute Pancreatitis
Elevated amylase/lipase, hypoperfusion of pancrease on CT=necrotizing pancreatitis -> IV hydration first - no Abx at first, ERCP only if gallstone
Achalasia
Laproscopy myotomy
if NOT surgical candidate then Botox injection EGD
Celiac Dz
IDA -> upper/lower scope neg -> repeat EGD with SBowel bx (even with TTG neg)
Microscopic Colitis
chronic watery diarrhea - abn thickened mucosa in colon - can be caused by lansaprozole, NSAIDS, raniditine, setraline
withdraw meds then given mesalamine/budesondie
Opioid Induced Constipation
Add methylnaltrexone (micro opiod antagonist)
Refractory Hepatic Encephalopathy despite lactulose
Rifaxamine
Chronic Mesenteric Ishemia
abd pain after eating in vasculopath -> Wt loss
Dx: Angiography (high lactate)
Tx: Angioplastic vs surgical revascularization
Inadequate Bowel Prep Screening colonoscopy
Reprep bowel and screen again NOW
Colonoscopy Polyp Surveillence
10 years - no polyps or only small rectal hyperplastic polyps
5 years - 1 or 2 small (<1cm)
Hereditary nonpolyposis Colorectal CA syndrome
Colonoscopy age 20-25 or 10 years before youngest family member dx
Non ETOH steatohepatitis
Serial LFT monitoring, weight loss, excercise, agressive control of glucose, lipids, BP
Continue Statin even if LFTs elevated
SBP with hepatic and renal dysfxn
Cefotaxime AND albumin - don’t use diuretics or large volume paracentesis with renal failure
