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USMLE Step 2 CK > Gastroenterology (Internal Medicine) > Flashcards

Gastroenterology (Internal Medicine) Flashcards

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USMLE® Step 1 flashcards
1
Q

How is hiatal hernia diagnosed?

A

Endoscopy or barium studies

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2
Q

What is the BEST INITIAL therapy for hiatal hernia?

A

Weight loss and PPI’s

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3
Q

If the initial therapy does not work and the symptoms of hiatal hernia persist, what is done next?

A

Surgical correction - Nissen fundoplication

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4
Q

What are alarm symptoms indicating endoscopy?

A

Weight loss
Blood in stool or heme + stool
Anemia

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5
Q

Why is endoscopy performed when alarm symptoms are present?

A

To exclude cancer

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6
Q

What is the common presentation for achalasia?

A

Patient younger than 50 y/o
Progressive dysphagia to both solids and liquids at the same time
No association with alcohol or tobacco use

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7
Q

What is the MOST ACCURATE test to diagnose achalasia?

A

Manometry - It will show failure of the LES to relax

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8
Q

How else can achalasia be diagnosed?

A

Barium esophagram - Shows “bird beak”
CXR - Abnormal widening of the esophagus (not sensitive or specific)

Upper endoscopy would show normal mucosa, but endoscopy is useful to exclude malignancy

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9
Q

What is treatment for achalasia based on?

A

Mechanical dilation of the esophagus

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10
Q

What are treatment options for achalasia?

A

Pneumatic dilation - Effective in >80-85% of patients
Surgical sectioning or myotomy - More effective than pneumatic dilation but more dangerous
Botulinum toxin injection - Effects wear off in about 3 to 6 months, requiring reinjection.

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11
Q

How does esophageal cancer present?

A

Patient over 50 y/o
Dysphagia first for solids, that later progresses to dysphagia for liquids.
Association with prolonged alcohol and tobacco use
More than 5-10 years of GERD symptoms.

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12
Q

How is esophageal cancer diagnosed?

A

Endoscopy with biopsy - only way to dx cancer

Barium might be the best initial test (no radiologic test can dx cancer)

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13
Q

In esophageal cancer, what are CT and MRI scans used for?

A

To determine the extent of spread into surrounding tissues.

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14
Q

What is a PET scan used for in esophageal cancer?

A

To determine contents of anatomic lesions (verify cancer)

To determine if a cancer is resectable.

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15
Q

What are treatment options for esophageal cancer?

A

Surgical resection - Always try
Chemotherapy and radiations (in addition to resection)
Stent placement - Used to keep the esophagus open, improving dysphagia in non resectable lesions as part of palliation.

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16
Q

How does esophageal spasms present?

A

Sudden, severe chest pain
May be precipitated by drinking cold liquids
Normal EKG and stress test
Normal esophagram and endoscopy

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17
Q

What is the MOST ACCURATE test to diagnose esophageal spasms?

A

Manometry: There will be a different pattern of abnormal contraction for diffuse esophageal spasm (DES) and nutcracker esophagus.

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18
Q

How are esophageal spasms treated?

A

Calcium channel blockers (CCB) and nitrates
PPI’s improve some cases
TCA’s can be used instead of CCB
If all fails, use Sildenafil

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19
Q

What are common findings in eosinophilic esophagitis?

A

Dysphagia
Food impaction
Heartburn
History of asthma and allergic diseases

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20
Q

What is the MOST ACCURATE diagnostic test in eosinophilic esophagitis?

A

A biopsy finding eosinophils

Endoscopy shows multiple concentric rings

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21
Q

What is the BEST INITIAL therapy for eosinophilic esophagitis?

A

PPI’s and eliminating allergenic foods

If not effective, swallowing steroid inhalers.

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22
Q

What are common findings in Schatzki rings?

A

Acid reflux
Intermittent dysphagia
Associated to hiatal hernia
Distal esophagus

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23
Q

How are Schatzki rings detected?

A

Rings are seen in barium studies.

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24
Q

How are Schatzki rings treated?

A

Pneumatic dilation

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25
Q

What are common findings in Plummer-Vinson Syndrome?

A

Iron deficiency anemia
Dysphagia
Proximal esophagus

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26
Q

How is Plummer-Vinson Syndrome treated?

A

Iron replacement

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27
Q

What pills can cause esophagitis in prolonged contact?

A

Doxycycline
Alendronate (Biphosphonate)
KCl

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28
Q

What are the only conditions diagnosed through esophageal biopsy?

A

Barret esophagus

Esophageal cancer

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29
Q

What are common findings in Zenker diverticulum?

A

Dysphagia
Halitosis
Regurgitation of food particles

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30
Q

How is Zenker diverticulum best diagnosed?

A

Barium studies

Upper endoscopy or even NGT placement may cause perforation.

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31
Q

What are findings in scleroderma?

A

Symptoms of reflux + history of scleroderma or progressive systemic sclerosis

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32
Q

How is scleroderma changes in the esophagus diagnosed?

A

Manometry - Shows decreased LES pressure from inability to close LES.

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33
Q

How is scleroderma managed?

A

PPI’s

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34
Q

Manometry is used to diagnose which diseases?

A

Achalasia
Spasm
Scleroderma

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35
Q

How are severe cases of Mallory Weiss managed?

A

Injection of epinephrine - stops bleeding or

Electrocautery

36
Q

How does Cannabinoid Hyperemesis Syndrome present?

A

History of cannabis use
Recurrent episodes of nausea, vomiting and crampy abdominal pain.
Improvement of symptoms with a hot shower or bath

37
Q

How is epigastric pain treated?

A

PPI’s
H2 blockers - NOT as effective
Liquid antacids - As above

38
Q

How does Gastroesophageal Reflux Disease (GERD) present?

A 
Epigastric burning pain radiating up into the chest (or under the sternum) 
Sore throat
Bad taste in the most (metallic)
Hoarseness
Cough
39
Q

What worsens symptoms of GERD?

A 
Nicotine
Alcohol
Caffeine
Chocolate 
Peppermint 
Late night meals
Obesity
40
Q

How is GERD diagnosed?

A

Based on patient history

If the diagnosis is not clear, 24 hour pH monitoring is done to confirm etiology.

41
Q

In GERD, when is endoscopy indicated?

A

Signs of obstruction like dysphagia or odynophagia
Weight loss
Anemia or heme + stool
More than 5-10 years of symptoms (exclude Barret esophagus)

Redness, erosions, ulcerations, strictures, or Barrett esophagus

42
Q

What are the overall recommendations for GERD?

A

Lose weight if obese
Avoid alcohol, nicotine, caffeine, chocolate and peppermint
Avoid eating at night before sleep (within 3 hrs of bedtime)
Elevate head of bed 6-8 inches

43
Q

How is mild or intermittent symptoms of GERD treated?

A

Liquid antacids or H2 blockers

44
Q

How are persistent symptoms or GERD or erosive esophagitis treated?

A

PPI’s

45
Q

How are patients not responsive to medical therapy treated?

A

Surgical or anatomic correction to tighten the lower esophageal sphincter:
Nissen fundoplication - Wrapping stomach around LES
Endoninch: Suture around LES to tighten it
Local heat or radiation of LES to cause scarring

46
Q

How is Barrett Esophagus diagnosed?

A

Biopsy detects columnar metaplasia.

47
Q

Which Barrett Esophagus has the greatest risk of transforming into esophageal cancer?

A

Columnar metaplasia WITH intestinal features (nonciliated columnar with goblet cells)

48
Q

How is Barrett Esophagus (alone) managed?

A

PPI’s

Rescope every 2-3 years

49
Q

How is low grade dysplasia in Barrett esophagus managed?

A

PPI’s

Rescope every 6-12 months

50
Q

How is high grade dysplasia in Barrett esophagus managed?

A

Ablation with endoscopy:

Photodynamic therapy, radiofrequency ablation, endoscopic mucosal resection

51
Q

What can cause gastritis?

A 
Alcohol
NSAID's
Helicobacter pylori 
Portal hypertension
Stress (burns, trauma, sepsis and multiorgan failure)
52
Q

How does gastritis most commonly present?

A

GI bleeding without pain

Severe, erosive gastritis can present with epigastric pain.

53
Q

How can erosive gastritis be definitively diagnosed?

A

Upper endoscopy

Test for H.pylori, to be treated in case it is associated with gastritis.

54
Q

What is the MOST ACCURATE test for H. pylori?

A

Endoscopic biopsy

55
Q

What test for H.pylori lacks specificity?

A

Serology (blood)

A positive result does not differentiate between current and previous infection
A negative result excludes the infection

56
Q

What tests detect active infection with H. pylori?

A

Urea C13 or C14 breath testing

H.pylori stool antigen

57
Q

What is the treatment for gastritis?

A

PPI’s

58
Q

When is stress ulcer prophylaxis indicated?

A

Mechanical ventilation
Burns
Head trauma
Coagulopathy

59
Q

How is a duodenal ulcer differentiated from a gastric ulcer?

A

Endoscopy

60
Q

What commonly causes Peptic Ulcer Disease (PUD)?

A

Helicobacter pylori
NSAID’s

Less common:
Burns 
Head trauma
Chronic disease 
Gastric cancer 
Gastrinoma (Zollinger-Ellison syndrome)
61
Q

What causes delayed healing in ulcers?

A

Alcohol and tobacco use

62
Q

How does Peptic Ulcer Disease (PUD) present?

A

Recurrent episodes of epigastric pain described as dull, sore and gnawing.

63
Q

Duodenal ulcer VS Gastric ulcer

A

Duodenal ulcer improves with eating - patient gains weight

Gastric ulcer worsens with eating - patient loses weight

64
Q

Endoscopy definitively distinguishes between which diseases?

A

Duodenal ulcer
Gastric ulcer
Gastritis
Non ulcer dyspepsia

65
Q

What is the MOST ACCURATE diagnostic test for PUD?

A

Upper endoscopy

Upper GI series can detect ulcers but not cancer or H.pylori

66
Q

What is the risk of cancer in PUD?

A

Cancer is present in 4% of gastric ulcers but NOT in duodenal ulcers

67
Q

What is the treatment for PUD?

A

PPI’s

68
Q

Is H.pylori associated with PUD?

A

Duodenal ulcers are associated with H.pylori in over 80% to 90% of cases.

Gastric ulcers associated with H.pylori in 50% to 70% of cases.

69
Q

What is the BEST INITIAL therapy for H.pylori?

A

PPI combined with clarithromycin and amoxicillin.

Those who do not respond:
Detect persistent H.pylori and switch abx to metronidazole and tetracycline. Adding bismuth to a change in abx may aid in resolution of treatment resistant ulcers.

In gastric ulcers, repeat endoscopy to exclude cancer.

Retest with stool antigen or breath test to confirm cure of H.pylori.

70
Q

Treatment failure in H.pylori can stem from?

A

Nonadherence to medications
Alcohol
Tobacco
NSAIDs

71
Q

How is Non Ulcer Dyspepsia diagnosed?

A

Only after endoscopy

72
Q

How is Non Ulcer Dyspepsia managed?

A

Under 45 y/o: Empirically tx with PPI’s (antisecretory therapy); scope only if symptoms do not resolve.

Over 55 y/o: Do endoscopy to exclude cancer.

Endoscopy is also performed if alarm symptoms are present (dysphagia, weight loss, anemia)

73
Q

What is the most common cause of epigastric pain?

A

Non Ulcer Dyspepsia (NUD)

74
Q

What is the BEST INITIAL therapy for NUD?

A

PPI’s

75
Q

How does Gastrinoma present?

A

Multiple large ulcers (>1-2cm)
Recurrent after Helicobacter eradication
Distal in the duodenum

76
Q

How is a Gastrinoma confirmed?

A

Detecting ulcers through endoscopy

77
Q

What is the MOST ACCURATE diagnostic test for Gastrinoma?

A

Persistent high gastrin levels despite injecting secretin. (Considered a functional test).

High gastrin levels off antisecretory therapy (PPI’s or H2 blockers)with high gastric acidity.

High gastrin levels despite a high gastric acid ouput.

78
Q

What is done after confirming a Gastrinoma?

A

CT and MRI of the abdomen (to exclude metastatic disease, although a negative imaging does not exclude metastases).

79
Q

How can metastatic disease be excluded with Gastrinoma?

A

Somatostatin receptor scintigraphy (nuclear octeotride scan) combined with endoscopic ultrasound.

80
Q

How is Gastrinoma treated?

A

Local: Remove surgically
Metastatic: Lifelong PPI’s (because it is unresectable).

81
Q

What is Diabetic Gastroparesis?

A

Autonomic neuropathy leading to dysmotility. Dysmotility results from the inability to sense stretch in the GI tract.

82
Q

How does Diabetic Gastroparesis present?

A

History of diabetes
Chronic abdominal discomfort, bloating and constipation.
Anorexia, nausea, vomiting and early satiety.

83
Q

What is the BEST INITIAL test for Diabetic Gastroparesis?

A

Upper endoscopy or abdominal CT scan.

Excludes a luminal gastric mass or an abdominal mass compressing the stomach.

84
Q

What is the MOST ACCURATE test for Diabetic Gastroparesis?

A

Nuclear gastric emptying study (bolus of food tagged with technetium).

A delay in emptying of food indicates gastroparesis.

85
Q

What is the BEST INITIAL therapy for Diabetic Gastroparesis?

A

Dietary modification:
Blenderized foods
Fluid restoration
Correction of potassium and glucose levels.

86
Q

How to manage Diabetic Gastroparesis if the initial therapy does not work?

A

Metoclopramide
(Cannot be used permantly due to side effects: dystonia and hyperprolactinemia).

If metoclopramide is ineffective, can use erythromycin and antiemetics.

If all medical fails, gastric electrical stimulation (gastric pacemaker).

USMLE Step 2 CK (2 decks)

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