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USMLE Step 2 CK > GastroIntestinal > Flashcards

GastroIntestinal Flashcards

Know G.I.

1
Q

Dysphagia

A

Difficulty swallowing

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2
Q

Odynophagia

A

Pain with swallowing

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3
Q

Esophageal Webs

A
  • Associated with Iron Deficiency Anemia
  • Glossitis

(Plummer-Vinson Syndrome)

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4
Q

Dysphagia

Dx

A

Esophageal Dysphagia:

  • Barium Swallow followed by
  • endoscopy

If obstructive lesion shows then BIOPSY

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5
Q

Diffuse Esophageal Spasm

A

Motility disorder which normal peristalsis is periodically interrupted by high amplitude nonperistaltic contractions

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6
Q

Diffuse Esophageal Spasms

HX / PE

A
  • Chest Pain
  • Dysphagia
  • Odynophagia
  • Precipitated by ingestion of hot or cold liquids
  • relieved by nitroglycerin
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7
Q

Diffuse Esophageal Spasms

Dx & Tx

A

Dx- Barium Swallow (cork screw esophagus)

Tx- Nitrates and CCB’s
- Surgery for SEVERE problems

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8
Q

Achalasia

A

Impaired relaxation of lower esophageal sphincter (LES)

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9
Q

Achalasia

Hx / PE

A
  • Progressive dysphagia
  • Chest pain
  • Regurgitation of undigested food
  • Weight loss
  • Nocturnal cough
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10
Q

Achalasia

Dx

A

1st- Barium Swallow : shows dilation, “birds beak”

  • Manometry shows increase resting LES pressure
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11
Q

Achalasia

Tx

A

Nitrates
CCB’s
Inject botulinum into LES
Pneumatic balloon dilation or surgical myotomy

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12
Q

Esophageal Cancer

A
  • Squamous Cell Carcinoma (SCC) is most common.

- Adenocarcinoma is most prevalent in USA (Barrett’s Esophagus)

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13
Q

Esophageal Cancer

Hx / PE

A
  • Progressive dysphagia (solids first then liquid)
  • Weight Loss
  • GERD
  • GI Bleeding
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14
Q

Esophageal Cancer

Dx

A

1st- Barium Study
2nd- Biopsy confirms
- CT and Endoscopic used for staging

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15
Q

Esophageal Cancer

Tx

A
  • ChemoRadiation and surgical resection if definitive tx
  • Prognosis is poor

Cancer Metastasizes early because esophagus lacks a serosa

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16
Q

GastroEsophageal Reflux Disease (GERD)

A

Reflux of gastric contents into the esophagus

  • from transient LES relaxtion
  • due to incompetent LES, Gastroparesis or Hiatal hernia
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17
Q

GERD

Dx

A

Hx and Clinical impression

  • Trial of lifestyle modification and tx attempted first
  • Studies maybe a Barium Swallow to look for Hiatal hernia
  • EGD with biospy should be done in pt with symptoms unresponsive to initial therapy
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18
Q

GERD Tx

A

Liftstyle Change

  • Weight loss
  • Head of bed elevation
  • Reduce meal size
  • Avoid Noctural meals

Pharm

  • Antacids
  • H2 antagonists (cimdetidine) or PPI (omeprazole) in chronic and frequent symptoms
  • Surgical (Nissen Fundoplication) for SEVERE disease
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19
Q

GERD Avoid what types of food

A
  • Caffeine
  • Alcohol
  • Chocolate
  • Garlic
  • Onions
  • Mints
  • Nicotine
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20
Q

Hiatal Hernia

A

Herniation of a Portion of stomach upwards into the chest through a diaphragmatic opening

  • Sliding (95%)- Gastroesophageal junction and portion of stomach displaced above diaphram
  • Paraesophageal (5%)- Gastroesophgeal remains below diaphram, but portion of fundus goes into mediastinum
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21
Q

Hiatal Hernia

Dx / PE

A

May be asymptomatic

Sliding may present with GERD

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22
Q

Hiatal Hernia

Dx a& Tx

A

Dx- Commonly incidental finding on CXR
- DX by Barium Swallow or EGD

Tx-
Sliding- Medical Therapy and life style mods
to decrease GERD

Paraesophageal- Surgical gastropexy (Attach stomach to rectus sheath and closure of hiatus)

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23
Q

Gastritis

A

Inflammation of the stomach lining

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24
Q

Gastritis

Subtypes (3)

A

Acute: rapid develop

  • Due to NSAIDS
  • Alcohol
  • H. Pylori
  • Stress

Chronic Type A (10%)

  • Occurs in Fundus
  • Due to Autoantibodies of parietal cells
    - causes Pernicious anemia

Chronic Type B (90%)

  • Occurs in Antrum
  • Due to NSAIDS or H. Pylori
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25
Gastritis Hx / PE
Maybe Asymptomatic - epigastric pain - Nausea - Vomiting - Hematemesis - Melena
26
Gastritis Dx
Upper Endoscopy visulizes gastric lining H. Pylori detect by Urease Breath Test - IgG indicates exposure
27
Gastritis Tx
- Antacids, H2 blockers, PPI - Triple Therapy (Amoxicillin, Clarithromycin, Omeprazole) - Prophylactic H2 or PPI for risk of stress ulcers
28
Gastric Cancer
Tumors generally Adenocarcinoma 2 types - Intestinal: arises by H. pylori - Diffuse- Signet Sing Cells seen
29
Gastric Cancer Hx / PE
Early Signs - Indigestion - Loss Appetite Advanced - Ab pain - Weight loss - Upper GI bleed
30
Gastric Cancer Dx & Tx
Early - discovered serendipitously with endoscopic exam Tx- successful tx rests on early detection and surgical removal 5 year survival rate <10% in advanced disease
31
Peptic Ulcer Disease (PUD)
Damage to gastric or duodenal mucose caused by impaired mucosal defense and/or gastric contents
32
PUD Hx / PE
Duodenal Ulcers - Dull - Buring epigastric pain - Improves with means Gastric - Pain right after meals - "Coffee ground emesis) - Blood in stool
33
Gastric Cancer Has Virchow's Node what is it located
Enlarged Left SupraClavicular Lymph Node
34
PUD PE
- Exam reveal epigastric tenderness - + Stool guaiac - Acute perforation can present with rigid abdomen - rebound tenderness - Guarding - peritoneal irritation
35
PUD DX
- AXR rule out perforation (free air under diaphram) - CBC assess for GI bleed (Low hematocrit) - Upper Endoscopy with biopsy to confirm PUD - H. Pylori test
36
PUD Tx
Acute - rule out active bleed with Serial Hematocrits - Rectal exam with stool guaiac - Monitor B.P. - Perforation- SURGICAL Pharm - Protect Mucosa Mild - Antacids - Misoprostal for mucosal production - Pt with H. Pylori (give triple antiobiotics) - Dicontinue exacerbating agents Endoscopy and Surgery - Symptoms for > 2 months and refractory
37
Diarrhea 4 etiologic mechanisms?
Production of > 200 g of feces per day along with increase frequency or decrease consistency of stool 4 etiologic mechanisms - Increase motility - Increase Secretion - Increase luminal osmolarity - Increase inflammation
38
Diarrhea He / PE
Acute - < 2 weeks of symptoms - usually infectious and self limited Preformed Toxins - S. Aureus - Bacillus Non-invasive - E-coli - Vibrio - C. Difficle ``` Invasive - Enteroinvasive E-Coli - Salmonella - Singella Campylobacter ``` Parasite - Giardia - Entamoeba Histolitica Peds - Rotavirus (common during winter)
39
Chronic Diarrhea
Insidious onset >4 week of symptoms Due to increase secretion (carcinoid, vipoma) Malabsorption/osmotic - Bacterial overgrowth - Pancreatic insufficiency - lactose intolerance Inflammatory Bowel Disease
40
Diarrhea DX
Acute - No lab required - No investigation unless high fever, blood and > 5 days - Consider SIGMOIDOSCOPY in patients with bloody diarrhea
41
Diarrhea TX
Acute - no bacterial infection - treat with antidiarrheal (loperamide) and ORAL rehydration Chronic - Identify underlying cause - tx symptoms - loperamide - opioids Peds - Hospitalize - IV fluids - repleate Electrolytes
42
Carcinoid Syndrome
Due to liver metastasis of Carcinoid Tumors Arise from Ileum and Appendix Produce vasoactive substances like serotonin and substance P.
43
Carcinoid Syndrome HX / PE
- Cutaneous flushing - Diarrhea - Ab cramps - Wheezing - Right sided valvular heart lesions
44
Carcinoid Dx
High urine levels of 5-HIAA (serotonin Metabolite)
45
Carcinoid Tx
Octreotide (for symptoms) Debulking of tumor mass
46
Small Bowel Obstruction (SBO)
Blocked passage of bowl contents through the small bowel. Leading to fluid and electrolyte imbalances, ab discomfort Obstruction can be - Complete - Partial & - Ischemic - Necrosis
47
SBO occur due to what?
- Adhesions (60%) - Hernia (20%) - Neoplasms (20%) - Intussusception - Gallstone Ileus - Stricture
48
SBO HX / PE
- Cram ab pain with crescendo-decrescendo pattern 5 - 10 min intervals - Vomiting - Partial (no stool but has faltulance) - Complete (no stool or flatulance) - Bowel sounds: high pitch tinckles
49
SBO DX
CBC - Leukocytosis (if ischemic or necrosis) Labs - Dehyration - Metabolic Alkalosis (due to vomit) - Lactic Acidosis (necrotic bowel) AXR - Stepladder pattern of dilated small bowel loops - Air fluid levels Children - Hernia Adults - Adhesions
50
SBO Tx
Partial - Supportive care - NPO - NG suction - IV hydration - Correct electrolytes - Foley Cath to monitor fluid Surgery - required of complete SBO - Vascular compromise - > 3 days without improvements
51
Ileus
Loss of peristalsis without structural obstruction
52
Ileus Risks
- Recent surgery - Recent GI procedure - Severe Medical Illness - Immobility - Hypokalemia - Hypothyroid - DM - Meds that slow GI motility
53
Ilieus Hx / PE
Symptoms - Diffuse, constant, moderate ab discomfort - N/V, especially with eating - Absence of flatulence or BM Exam - Tenderness - Ab distention - No peritoneal signs - Decrease or abscent bowel sounds
54
Ilieus Dx & Tx
- Distended loops of small and large bowel on supine AXR with airfluid levels on upright view Tx - Discontinue meds - Temporary discontinue oral feels - Initiate NG suction - Replete Electrolytes
55
Mesenteric Ischemia
Decrease blood supply leading to insufficient perfustion to intestinal tissue and ischemic injury
56
Mesenteric Ischemia HX / PE
- Severe ab pain out of proportion to the exam - Older people - Ab exam is unremarkable - N/V/D - Bloody stools
57
Mesenteric Ischemia Dx / Tx
Dx - Leukocytosis - Metabolic Acidosis with - increase lactate - Increase amylast - Increase LDH and CK Tx - Volume resuscitation - Broad spectrum antibiotics - Avoid vasoconstrictors - Anticoagulation
58
Diverticular Disease
Outpouching of mucosa and submucosa that herniate through the colonic muscle layers of high intraluminal pressure. Found in Sigmoid most common
59
Diverticulosis Seen mostly in what age? Risks?
- > 40 - Most common cause of acute lower GI bleed Risks - Low fiber - high fat diet
60
Diverticulitis
Inflammation and potentially perforation of diverticulum secondary to fecalith impaction
61
Diverticular HX / PE Diverticulitis HX/PE?
HX - Often asymptomatic - Bleeding is painless and sudden Diverticulitis - LLQ ab pain - Fever - N/V/C
62
Diverticulum DX & TX
Dx CBC - Leukocytosis - AXR Tx Uncomplicated Diverticulosis - Followed up and given high fiber diet Diverticular Bleed - Bleeds stop spontaneous - Transfuse and rehydrate as needed Diverticulitis - Bowel Rest (NPO) - NG tube - Broad Spectrum Antibiotics (Metronidazole and Quinilone or 2-3 gen ceph) AVOID Sigmoidoscopy's
63
Colon Cancer
Second leading cause of cancer mortality in the USA after lung Cancer Increase incidence with Age Peak incidence @ 70 y/o
64
Colon Cancer HX / PE
``` Hx Right sided lesions - Often bulky - Ulcerating masses - Weight loss - Anorexia - Diarrhea - Vague Ab Pain ``` Left- Sided - Apple core - Obstructing mass - Change in bowel Habits - Colicky Ab pain
65
Colon Cancer Dx
- CBC - Sigmoidscopy (Evaluate rectal bleed and left sided lesions) - Colonoscopy (right sided lesions) - Determine degree of invasion in Rectal Canacer with endorectal u/s Metastatic Workup - CXR - LFT - AB/Pelvic CT
66
Colon Cancer Tx
- Surgical Resection - Reginal Lymph node resection for staging - Adjuvant Chemo - used in colon cancer with + lymph nodes - Follow with serial CEA
67
Ischemic Colitis
Lack of arterial blood supply to the colon Severity ranges from superficial to full thickness necrosis
68
Ischemic Colitis Most common affected
- Splenic Flexure (watershed area)
69
Ischemic Colitis Hx / PE
- Crampy - Lower ab pain - Bloody Diarrhea
70
Ischemic Colitis DX and Tx
Dx CBC - Leukocytosis - Sigmoidoscopy or colonoscopy to assess colonic mucosa Tx - Bowel Rest - IV - Broad spectrum Antibiotics - Surgery with resection indicated for infarction
71
Inguinal Hernia's
Abdormal protrusions of Abdominal contents (usually small intestine) into the inguinal region. - Direct - Indirect Based on their relationship to inguinal canal
72
Indirect Hernia
Herniation of abdominal contents through the internal and then external inguinal rings and into the scrotum. MD don't LIE Due to congential patent processus vaginalis - Lateral to Inferior epigastic vessel
73
Direct hernia
Herniation of abdominal contents through floor of Hesselback's triangle - Protudes MEDIAL to epigastic vessel MD don't LIE Hernial sac contents do not transverse the internal inguinal ring. Stay in external oblique muscle - Acquired defect in transversalis fascia from mechanical breakdown through age
74
Hernia Tx
Risk of Incarceration and Strangulation Surgical management indicated unless specific contraindications.
75
Hesselback's Triangle
- Inguinal ligament - Inferior epigastric artery - Rectus Abdominis
76
Triangle of Calot What passes through structure
- Cystic Artery traingle made up of - Common hepatic duct - Cystic Duct - Inferior border of liver
77
Abnormal Liver Disease 3 patterns
Hepatocellular Injury - Increase AST and ALT Cholestasis - Increase Alkaline phosphatse and Bilirubin Isolated Hyperbilirubinemia - Increase bilirubin Jaundice- seen in all 3, shows up when bilirubin >2.5 mg/dL
78
Hepatitis
Inflammation of the liver leading to liver cell injury and necrosis
79
Cause of Acute Hepatitis
Virus (HAV, HBV, HCV) | Drugs (alcohol, acetaminophen, INH)
80
Causes of Chronic Hepatitis
Virus (HBC, HCV, HDV) Alcoholic Hepatitis Autoimmune Hepatitis Hereditary (Wilsons, Hemochromatosis)
81
HAV and HEV Transmitted?
Fecal-Oral Route
82
HBV and HCV Transmitted
Bodily Fluids Risk of acquiring HCV sexually is very low
83
Hepatitis HX / PE
Hx - Nonspecific Symptoms - N/V - Joint pain - Malaise - Fever - Jaundice and RUQ tenderness Exam - Jaundice - Scleral Icterus - Tender Hepatomegaly - Lymphadenopathy
84
Hepatitis DX
- Increase in AST and ALT - Increase Bilirubin / Alkaline Phosphatase Chronic Hep - ALT and AST increased >6 months Diagnosis - Hepatitis serology
85
Hepatitis TX Alcoholic Immunosuppressive
Steroids for Alcoholic Hepatitis Immunosuppression and steroids for Autoimmune - Liver transplant for end stage liver failure - IFN, Lamivudine for chronic HBV - Peginterferon and Ribavirin HCV
86
Cirrhosis
Fibrosis and nodular regeneration resulting in hepatocellular injury.
87
Cirrhosis Hx / PE
Presents with: - Jaundice - Ascites - Bacterial Peritonitis - Hepatic Encephalopthy - Gastroesophageal Varices - Renal Dysfunction Exam: - Enlarged, palpable or firm liver - Portal HTN
88
Cirrhosis DX
- Decrease Albumin - Increase PT/PTT - Increase Bilirubin Abdominal U/S/ - Assess liver size - Ascites - Patency of splenic and hepatic veins
89
Cirrhosis Tx
Ascites: - NA restriction and Diuretics - Rule out infections and neoplastic causes ``` Spontaneous Bacterial Peritonitis - Fever - Ab pain - Altered Mental Status - Check Peritoneal fluid Fluid + if >250 PMNs/Ml or >500 WBC - Treat IV antibiotics (3rd Gen Ceph) ``` Hepatorenal Syndrome - Diagnosis of exlusion - Needs Dialysis Hepatic Encephalopathy - Due to decrease clearance of ammonia - Tx with protein restriction - Lactulose - Rifaximin
90
Primary Biliary Cirrhosis
Autoimmune disorder characterized by: - destruction of intrahepatic bile ducts - Middle aged women with other autoimmune disorders
91
Primary Biliary Cirrhosis DX / PE
Presents: - Progressive jaundice - Pruritis - Malabsorption of Fat Soluable
92
Primary Biliary Cirrhosis Dx and Tx
Dx - Increase Alkaline Phosphatse - Increase Bilirubin - + anti-Mitochondrial Antibody - Increase Cholesterol Tx - Ursodeoxycholic Acid (slows diease) - Cholestyramine (pruritis) - Liver Transplant
93
Hepatocellular Carcinoma
Risk Factors - Cirrhosis - Chronic Hepatitis (HCV) - Aflatoxins - HBV inections
94
Hepatocellular Carcinoma HX / PE
Presents - RUQ Tenderness - Ab distention - Signs of chronic liver diesase - Jaundice - Easy Bruise - Coagulopathy PE - Enlarged liver
95
Hepatocellular Carcinoma DX & TX
Dx - U/S or CT - Liver Biopsy Definitive Diagnosis Tx - Small Tumors - Aggressive Tumor resection - Orthotopic liver transpantation Chemo and Radiation NOT effective - Monitor recurrence with serial AFP leverls
96
Hemochromatosis
Hyperabsorption of Iron with parenchymal hemosiderin accumulation in the liver, pancreas, heart, adrenals, testes, pituitary, and kidneys
97
Hemochromatosis is what type of recessive disease
Autosomal recessive Can be seen in Alcoholics as well, since alcohol increase iron absorption
98
Hemochromatosis Hx / PE
Presents: - Ab pain - Symptoms of DM - Hypogonadism - Arthropathy of MCP joints - Heart Failure - Cirrhosis ``` Exam: - Bronze Skin - Pancreatic dysfunction - Cardiac Dysfunctoin - Hepatomegaly _ Testicular Atriphy ```
99
Hemochromatosis DX
- Increase serum Iron - Decrease Serum Transferrin - TRANSFER SATURATION most SENSITIVE - Glucose intolerence - LIVER BIOPSY - Hepatic MRI
100
Hemochromatosis TX
- Weekly phlebotomy (ever 2-4 months) | - Deferoxamine
101
Wilson's Disease | Hepatolenticular Degeneration
- Decrease Ceruloplasmin - Excessive deposition of Copper in liver and brine - AR on Chromosome 13 - < 30
102
Wilson's Disease Hx / PE
Hx - present with Hemolytic Anemia - Liver Abnormalities - Neurologic - Psychiatric abnormalities PE - Kayser-Fleischer Rings (Green to brown deposits of copper)
103
Wilson's Disease Dx & Tx
- Decrease Serum Ceruloplasmin - Increase urinary copper excretion - Increase hepatic copper Tx - Dietary Copper restriction (avoid liver, shell fish) - Penicillamine
104
Wilson's ABCCCD
``` Asterixis Basal Ganglia Deterioration Ceruloplasmin Decrease Cirrhosis Copper Increase Carcinoma of Liver Choreiform movements Dementia ```
105
Pancreatic Cancer Risks what part of the pancreas
75% are adenocarcinom of the head of the pancreas Risks - Smoking - Chronic Pancreatitis - 1st degree relative with Pancreatic cancer - High fat diet
106
Pancreatic Cancer Hx / PE
Presents - Ab pain radiates toward back - Obstructive jaundice - Loss of apetite - N/V - Weight loss - Indigestion - Asymptomatic EXAM: - palpable nontender gallbladder (Courvoisier's Sign) - Migratory thrombophlebitis (Trousseau's Sign)
107
Pancreatic Cancer DX & Tx
Dx - CT to detect Mass - If NO mass use ERCP - CA 19-9 elevated Tx - Treatment is Palliative - 20% have no metastasis use Whipple procedure - Chemo with 5-FU and Gemcitabine may improve short term survival (5-10% survival 5 years)
108
Ranson's Criteria On Admission
"GA LAW" ``` Glucose >200 mg/dL Age >55 LDH >350 AST >250 WBC >16 000 ```
109
Ranson's Criteria After 48 hr
C HOBBS Ca < 60 mmHg Base excess >4 BUN increase by 5 Sequestered fluid >6L
110
Ranson's Criteria How it works
Ranson's predicts mortality associated with acute pancreatitis. 20% with 3-4 signs 40% with 5-6 signs 100% with >7 signs
111
Cholelithiasis & Biliary Colic Risks
Colic results from Tansient cystic duct blockage from impacted stones Risks- 4 F's - Fat - Female - Fertile - Forty
112
Cholelithiasis & Biliary Colic Hx / PE
Presents - Postprandial ab pain (RUQ) and radiates to the right subscapular area or Epigastrium - Pain Abrupt followed by gradual relief - N / V - Fatty Food intolerance - Dyspepsia - Flatulence PE - 80% asymptomatic - Exam RUQ tenderness - Palpaple gallbladder
113
Cholelithiasis & Biliary Colic Dx and Tx
Dx - RUQ U/S Tx - Cholecystectomy curative - Asymptomatic needs nothing Patients may need - Endoscopic Retrograde Cholangiopancrreatograpthy (ERCP) for common bile duct stone
114
Choledocholithiasis
Gallstone in Common Bile DUCT Symptoms vary according to degree of obstruction
115
Choledocholithiasis Hx / PE & Tx
Hx - Presents with - Biliary colic - Jaundice - Fever - Pancreatitis - Increase Alkaline Phosphatse - Increase Total Bilirubin Tx - ERCP and Cholecystectomy

USMLE Step 2 CK (5 decks)

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