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MKSAP > Gastroenterology and Hepatology > Flashcards

Gastroenterology and Hepatology Flashcards

1
Q

Dysphagia lusoria

A

Vascular extrinsic compression seen on CTA Head/Neck that causes dysphagia

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2
Q

Peroral endoscopic myotomy

A

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

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3
Q

Management of achalasia

A

Surgical = Definitive

Nifedipine = Patients who are poor surgical candidates

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4
Q

Diffuse esophageal spasm

A

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

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5
Q

Screening for patient w/ indefinite dysplasia on EGD

A

PPI for 6 months then repeat endoscopy

If still present, repeat in one year again

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6
Q

Screening for patient w/ low-grade or high-grade dysplasia on EGD

A

Endoscopic ablation therapy

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7
Q

Management of HBV in an expectant mother

A

Treat for HBV DNA levels >200,000 w/ tenofovir or lamivudine

Treat newborn w/ HBV vaccine and immunization if mother is positive for HBeAg

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8
Q

Bactrim injury to the liver

A

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

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9
Q

Treatment of laxative-resistant, opioid induced constipation

A

Two peripherally acting opioid antagonists, oral naldemedine or subq methylnatrexone, and nalogegol, a pegylated form of naloxone

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10
Q

Patient with Hereditary Hemochromatosis and consideration for liver biopsy

A

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

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11
Q

Risk factor that increases risk of upper GI Bleed w/ NSAID use

A

Concomitant ASA use for CV prophylaxis

Raises risk 2-4x fold

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12
Q

Gastric polyps

A

Hyperplastic => Malignant potential (esp. if >1cm or pedunculated)

Adenoma => FAP, Lynch; rescope at 1 yr then q3yrs after

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13
Q

What do 2/3 of pancreatic cancer patients develop in the 36 months preceding their diagnosis?

A

Type II DM

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14
Q

Most common cystic lesion found in the pancreas

A

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

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15
Q

Mucinous cystic neoplasm

A

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

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16
Q

Initial eval of a pancreatic neuroendocrine tumor

A 
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

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17
Q

Lab you can order when you are unsure of nature of diarrhea

A

Stool osmotic gap

<50 = Secretory diarrhea; >100 = osmotic

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18
Q

Meds to treat Short Bowel Syndrome

A

Glucagon-like peptide 2, teduglutide

Increase intestinal wet weight absorption and decrease parenteral support required in these patients

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19
Q

Isolated AP level rising in IBD patient

A

Suspect primary sclerosing cholangitis

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20
Q

Way to differentiate IBD from IBS

A

Fecal calprotectin

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21
Q

Steroid used to treat Crohn’s flares

A

Budesonide; experiences high first pass metabolism in the liver so there are minimal systemic effects

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22
Q

Azathioprine or 6-Mercaptopurine considerations when treating IBD

A

Test for TPMT gene =» patients w/ low activity are at higher risk for toxicity

Monitor CBC, LFTs

Rarely can cause hepatosplenic T-cell lymphoma

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23
Q

What to do if you identify latent TB prior to starting a TNF-a inhibitor

A

Treat for 2 months w/ isoniazid

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24
Q

Agent to use in severe Crohn’s if TNF-a inhibitors have failed

A

Ustekinumab (Stelera): anti IL-12 and IL-23 antibody that inhibits cytokine receptors on T cells

25
Q

Colonoscopy screening w/ severe IBD

A

Start 8 years after diagnosis then repeat annually

26
Q

Treatment of IBS-Diarrhea

A

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

27
Q

Stool softener

A

Docusate

28
Q

Classic triad in Chronic Mesenteric Ischemia

A
  1. Postprandial abdominal pain
  2. Sitophobia (fear of eating)
  3. Weight loss

-only seen in 30% of CMI patients

29
Q

Stimulant Laxatives

A

Senne

Bisacodyl

30
Q

Main cause for a chronic anal fissure

A

Rectal spasm; treat w/ CCBs or nitrates

Can also consider botulinum injection

31
Q

Treatment of IBS-Constipation

A

1st: Linaclotide
2nd: Lubiprostone
3rd: Miralax

32
Q

Treatment of IBS-Diarrhea

A

1st: Rifaximin (14 day course; can be repeated if needed)

Otherwise, loperamide, antispasmodics (peppermint oil), and TCAs all may have some benefit

33
Q

Narcotic-bowel syndrome

A

Paradoxical increase in abdominal pain w/ increasing doses of opioid medications (hyperalgesia)

Tx is to taper off if you can lol

34
Q

Classic triad in Chronic Mesenteric Ischemia

A
  1. Postprandial abdominal pain
  2. Sitophobia (fear of eating)
  3. Weight loss
35
Q

Imaging study to order if CT is concerning for right sided colonic ischemia

A

CT Abdomen Angiogram

-Need to r/out acute mesenteric ischemia

36
Q

Main cause for a chronic anal fissure

A

Rectal spasm; treat w/ CCBs or nitrates

37
Q

First test to order in elderly patient who has urge fecal incontinence

A

Abdominal XR

Want to make sure it is not due to excess stool burden

38
Q

Meds to discontinue in cirrhotics w/ portal HTN

A

NSAIDs, ACEIs

-This is because the compensatory upregulation of the RAAS is required to maintain systemic pressures

39
Q

Test to order when primary biliary cholangitis is suspected but anti-mitochondrial antibodies are negative

A

sp100 and gp210 antibodies

Will occur in 10% of patients

40
Q

Polyp location in FAP and Lynch syndromes

A

Lynch = Proximal colon

FAP= Distal colon

41
Q

Attenuated FAP

A

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

42
Q

Other screening to perform on FAP patients

A

Upper endoscopy to screen for duodenal adenocacrinoma

May see gastric polyps as well but these do NOT have malignant potential

43
Q

MutYH-associated polyposis

A

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

44
Q

Polymerase Proofreading-Associated Polyposis

A

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

45
Q

Juvenile Polyposis Syndrome

A

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

46
Q

Peuthz-Jeghers Syndrome

A

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

47
Q

PTEN Hamartoma Syndrome

A

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

48
Q

Candidates for pegylated interferon therapy for management of HBV

A

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

49
Q

Target goal of HBV therapy for immune active phase

A

HBeAg loss and anti-HBe seroconversion; f/up for 12 more months of tenofovir treatment after this

50
Q

Duration of HBV therapy who are in immune reactivation

A

Indefinitely, even after viral load decreases

51
Q

Renal association w/ HBV

A

Membranous glomerulonephritis

52
Q

When to use prophylactic instead of supportive therapy for someone who has HBsAg

A

Receiving B-cell depleting therapy (rituximab)
Prednisone >10mg/day for at least 4 weeks
Anthracycline therapy (rubicins)

53
Q

Management of severe alcoholic hepatitis

A

Prednisolone; reduces short term mortality by 46%; should be discontinued if bilirubin does not decrease by Day 7 due to increased infection risk

54
Q

Modern management of Wilson’s Disease

A

Trientine; works like penicillamine but less ADRs

Additionally, give zinc supplements to decrease intestinal absorption of copper

55
Q

Management of asymptomatic esophageal varices <5mm in size

A

Repeat EGD in 2 years unless decompensation occurs

56
Q

Stellate scar seen on liver on abdominal CT

A

Focal nodular hyperplasia; does not have malignant potential and does not require f/up unless it is a woman on OCPs

57
Q

Diagnosis of hepatocellular carcinoma

A

Multiphase-contrast enhanced CT or MRI

58
Q

Resection candidate for hepatocellular carcinoma

A

CTP Class A cirrhosis
No portal HTN or jaundice
Single lesion 5cm or less

59
Q

Management of acute and chronic portal vein thrombosis

A

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

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