Gastroenterology and Hepatology Flashcards
Dysphagia lusoria
Vascular extrinsic compression seen on CTA Head/Neck that causes dysphagia
Peroral endoscopic myotomy
Procedure for achalsia which involves creating a submucosal tunnel extending to the LES and then performing a myotomy
Resolves symptoms in 80% of patients
; need to do Nissen fundopilcation as well when doing this
Management of achalasia
Surgical = Definitive
Nifedipine = Patients who are poor surgical candidates
Diffuse esophageal spasm
Hypercontractile esophageal disorder associated w/ chest pain and dysphagia; responds to nitroglycerin therapy
Manometry shows >30mmHg w/ intermittent aperistaltic contractions
Tx: Trazadone, imipramine, or sildenafil
Screening for patient w/ indefinite dysplasia on EGD
PPI for 6 months then repeat endoscopy
If still present, repeat in one year again
Screening for patient w/ low-grade or high-grade dysplasia on EGD
Endoscopic ablation therapy
Management of HBV in an expectant mother
Treat for HBV DNA levels >200,000 w/ tenofovir or lamivudine
Treat newborn w/ HBV vaccine and immunization if mother is positive for HBeAg
Bactrim injury to the liver
Cholestatic in nature w/ elevated AP and bilirubin levels weeks after taking the medication
-Is still a diagnosis of exclusion and requires periodic CMP monitoring
Treatment of laxative-resistant, opioid induced constipation
Two peripherally acting opioid antagonists, oral naldemedine or subq methylnatrexone, and nalogegol, a pegylated form of naloxone
Patient with Hereditary Hemochromatosis and consideration for liver biopsy
If ferritin >1000 and elevated LFTs, patient needs liver biopsy to evaluate for cirrhosis
If cirrhosis is present, then EGD and RUQ US q6months should be obtained
Risk factor that increases risk of upper GI Bleed w/ NSAID use
Concomitant ASA use for CV prophylaxis
Raises risk 2-4x fold
Gastric polyps
Hyperplastic => Malignant potential (esp. if >1cm or pedunculated)
Adenoma => FAP, Lynch; rescope at 1 yr then q3yrs after
What do 2/3 of pancreatic cancer patients develop in the 36 months preceding their diagnosis?
Type II DM
Most common cystic lesion found in the pancreas
Intraductal Papillary Mucinous Neoplasm (IPMN)
Arise from a branched duct and have a LOW rate of malignant transformation
RFs for transformation = Size >3cm, symptoms, solid component to cyst
Mucinous cystic neoplasm
90% found in women; they have a thick fibrous capsule w/ epitheliod cells similar to ovarian stroma surrounding the lesion
CEA levels can be elevated; these lesions should be monitored
Initial eval of a pancreatic neuroendocrine tumor
Chromogranin A 5-hydroxyindoleacetic acid Gastrin Glucagon Insulin Proinsulin Pancreatic polypeptide Vasoactive intestinal polypeptide
*Most secrete gastrin or insulin but only 10-25% are active anyways
Lab you can order when you are unsure of nature of diarrhea
Stool osmotic gap
<50 = Secretory diarrhea; >100 = osmotic
Meds to treat Short Bowel Syndrome
Glucagon-like peptide 2, teduglutide
Increase intestinal wet weight absorption and decrease parenteral support required in these patients
Isolated AP level rising in IBD patient
Suspect primary sclerosing cholangitis
Way to differentiate IBD from IBS
Fecal calprotectin
Steroid used to treat Crohn’s flares
Budesonide; experiences high first pass metabolism in the liver so there are minimal systemic effects
Azathioprine or 6-Mercaptopurine considerations when treating IBD
Test for TPMT gene =» patients w/ low activity are at higher risk for toxicity
Monitor CBC, LFTs
Rarely can cause hepatosplenic T-cell lymphoma
What to do if you identify latent TB prior to starting a TNF-a inhibitor
Treat for 2 months w/ isoniazid
Agent to use in severe Crohn’s if TNF-a inhibitors have failed
Ustekinumab (Stelera): anti IL-12 and IL-23 antibody that inhibits cytokine receptors on T cells
Colonoscopy screening w/ severe IBD
Start 8 years after diagnosis then repeat annually
Treatment of IBS-Diarrhea
1st: Rifaximin (14 day course; can be repeated if needed)
Other lines should be prescribed by GI doc
Otherwise, loperamide, antispasmodics (peppermint oil), and TCAs all may have some benefit
Stool softener
Docusate
Classic triad in Chronic Mesenteric Ischemia
- Postprandial abdominal pain
- Sitophobia (fear of eating)
- Weight loss
-only seen in 30% of CMI patients
Stimulant Laxatives
Senne
Bisacodyl
Main cause for a chronic anal fissure
Rectal spasm; treat w/ CCBs or nitrates
Can also consider botulinum injection
Treatment of IBS-Constipation
1st: Linaclotide
2nd: Lubiprostone
3rd: Miralax
Treatment of IBS-Diarrhea
1st: Rifaximin (14 day course; can be repeated if needed)
Otherwise, loperamide, antispasmodics (peppermint oil), and TCAs all may have some benefit
Narcotic-bowel syndrome
Paradoxical increase in abdominal pain w/ increasing doses of opioid medications (hyperalgesia)
Tx is to taper off if you can lol
Classic triad in Chronic Mesenteric Ischemia
- Postprandial abdominal pain
- Sitophobia (fear of eating)
- Weight loss
Imaging study to order if CT is concerning for right sided colonic ischemia
CT Abdomen Angiogram
-Need to r/out acute mesenteric ischemia
Main cause for a chronic anal fissure
Rectal spasm; treat w/ CCBs or nitrates
First test to order in elderly patient who has urge fecal incontinence
Abdominal XR
Want to make sure it is not due to excess stool burden
Meds to discontinue in cirrhotics w/ portal HTN
NSAIDs, ACEIs
-This is because the compensatory upregulation of the RAAS is required to maintain systemic pressures
Test to order when primary biliary cholangitis is suspected but anti-mitochondrial antibodies are negative
sp100 and gp210 antibodies
Will occur in 10% of patients
Polyp location in FAP and Lynch syndromes
Lynch = Proximal colon
FAP= Distal colon
Attenuated FAP
Version of FAP causing less polyps and usually in more proximal colonic distribution; patients have a 70% risk of cancer by age 80 (relative to 93% by 50 in classic FAP)
Screening can be delayed to age 20
Other screening to perform on FAP patients
Upper endoscopy to screen for duodenal adenocacrinoma
May see gastric polyps as well but these do NOT have malignant potential
MutYH-associated polyposis
AR condition caused by mutations in the mutYH gene that is a component in base-excision repair; management is similar to that of traditional FAP
Polymerase Proofreading-Associated Polyposis
AD conditions with features of both Lynch and RAP; caused by mutations in polymerase-proofreading genes in POLE and POLD1
Endometrial cancer has also been described in this syndrome; current management is similar to FAP
Juvenile Polyposis Syndrome
Caused by mutation in BMPR1A or SMAD4 genes; characterized by juvenile polyps (appear erythematous and waxy serrated-type)
Increased risk for colon, stomach, and small bowel cancer in young age
Peuthz-Jeghers Syndrome
Caused by mutations in the STK11 gene and associated w/ hyperpigmented mucocutaneous lesions most commonly on the lips but also seen in the nose, perianal, and genital ares
***Patients at high risk for small bowel hamartomas tha may develop at young age and present w/ intussusception, obstruction, and bleeding
PTEN Hamartoma Syndrome
Cowden Syndrome; caused by mutation in the tumor suppressor gene PTEN
Associated w/ GI hamartomas and breast, kidney, thyroid, and colon cancer
**Also associated w/ macrocephaly, esophageal glycogenic acanthosis (hyperkeratinzed, pale appearing lesions on EGD), and other dermatological manifestations
Candidates for pegylated interferon therapy for management of HBV
Patients who desire finite therapy, are not pregnant, and do not have significant coexisting cardiac/seizure/psychiatric/AI disease
Additionally, patients must have high ALT levels, low HBV DNA levels, and no cirrhosis
Target goal of HBV therapy for immune active phase
HBeAg loss and anti-HBe seroconversion; f/up for 12 more months of tenofovir treatment after this
Duration of HBV therapy who are in immune reactivation
Indefinitely, even after viral load decreases
Renal association w/ HBV
Membranous glomerulonephritis
When to use prophylactic instead of supportive therapy for someone who has HBsAg
Receiving B-cell depleting therapy (rituximab)
Prednisone >10mg/day for at least 4 weeks
Anthracycline therapy (rubicins)
Management of severe alcoholic hepatitis
Prednisolone; reduces short term mortality by 46%; should be discontinued if bilirubin does not decrease by Day 7 due to increased infection risk
Modern management of Wilson’s Disease
Trientine; works like penicillamine but less ADRs
Additionally, give zinc supplements to decrease intestinal absorption of copper
Management of asymptomatic esophageal varices <5mm in size
Repeat EGD in 2 years unless decompensation occurs
Stellate scar seen on liver on abdominal CT
Focal nodular hyperplasia; does not have malignant potential and does not require f/up unless it is a woman on OCPs
Diagnosis of hepatocellular carcinoma
Multiphase-contrast enhanced CT or MRI
Resection candidate for hepatocellular carcinoma
CTP Class A cirrhosis
No portal HTN or jaundice
Single lesion 5cm or less
Management of acute and chronic portal vein thrombosis
Acute: Anticoagulate if Hgb is stable (may have variceal hemorrhaging) and there is concern for extension to the superior mesenteric vein risking intestinal ischemia
Chronic: Nothing
