Gastrointestinal - 50% Flashcards

Question

Chronic Pancreatitis tx

Answer 1

Pancreaticojejunostomy -\> Whipple PO Pancreatic enzyme replacement ETOH abstinence Pain control

Answer 2

**Colonoscopy with bx - gold** barium enema - **apple core lesion** + CEA - marker CBC - anemia

Answer 3

3rd MC Cancer in US Genetics Familial Adenomatous Polyposis (APC gene - develop colon cancer by 40yo —\> prophylactic colectomy RFs * age \> 50yo - * UC \> Crohn's - * Low fiber diet - * smoking - * etoh - * AAs - * fam hx of CRC

Answer 4

average risk * start at 50 yo * FOBT q 1 year * Colonoscopy q 10y or Flex sig q 5 y 1st degree Relative or high RFs * FOBT q1y * starting at 40y or 10 yrs younger than earliest dx age Colo - q 5y Highest risk * UC or Crohn's \>8yrs, * FAP * FOBT any age * Colonoscopy q5y

Answer 5

MCC large bowel obstruction in adults Painless rectal bleeding; changes in bowel habits **Right sided** * proximal - lesions tend to bleed * (anemia/+ FOBT) diarrhea **Left sided** * distal bowel obstructions; present later * hematochezia * +changes in stool diameters

Answer 6

localized (stage 1 to 3) - resection Stage 3 to Mets - chemotherapy with 5FU/Fluorouracil

Answer 7

Inflammation of colon d/t C. Diff 2/2 abx penicillin, cephalosporins, FQ disrupts normal colonic flora Sxs * Mild watery foul smelling diarrhea (\>3 but \< 20 stools/d) * Fever * Abd pain, gen constitutional sxs Dx * PCR - C diff toxin- Toxin B (clinically important) * Stool culture * Leukocytosis Tx * IV metronidazole, or PO Vanc * Strict hand washing * Complications - bowel perf/ toxic megacolon

Answer 8

**gold - CT scan** FOBT + CBC Leuks Tx: * Abx - Cipro/Bactrim + MNZ * Clear liquid diet * colonoscopy in 6 wks to r/o cancer

Answer 9

Infection and inflammation of outpouchings d/t fecalith Sxs: * LLQ abd pain * Fever N/V/D * Constipation * bowel changes and bloating

Answer 10

CT - TOC\*\*\* * avoid barium enema Tx: * high fiber diet * psyllium - fiber supplement

Answer 11

Outpouchings d/t intestinal mucosa herniation Sxs: * **MCC BRBPR** * Low fiber diet * LLQ discomfort * fever, chills

Answer 12

Endoscopy with Bx - gold Barium esophagram CT for staging Esophageal resection chemo 5FU

Answer 13

MCC esophageal ca in US a/w Barrett's esophagus and GERD Sxs: * progressive dysphagia solids -\> fluids odynophagia * chest pain not related to eating * wt loss * reflux hoarseness

Answer 14

MCC Esophageal worldwide upper 1/3 of esophagus 50-70yo a/w smoking/etoh

Answer 15

Strictures - scarring from healing process of ulcerative esophagitis **_Schatzki Ring_** - diaphragm mucosal ring that causes sxs if is too small. Sxs * solid food dysphage w/ hx of GERD Dx * Barium swallow Tx * Endoscopy and dilatation * sx rarely needed

Answer 16

Endoscopy with Biopsy * **Linitis plastica** - thickening of gastric wall; rigid stomach from extensive malignancy Unresectability - vascular involvement of * **aorta** * **hepatic artery** * **proximal splenic artery** poor prognosis

Answer 17

MC adenocarcinoma RFs: * **H pylori\*\*\*** salted, cured, pickled food * Etoh, Smoking * Blood type A **_WEAPON_** * Weight loss * Emesis * Anorexia * Pain/abd discomfort * Obstruction * Nausea Signs of Mets * **Virchow's Node** - L supraclavicular lymphadenopathy * **Irish Node** - L axillary node * **Sister Mary Joseph Node** - Periumbilical Nodule

Answer 18

Virchow's Node - Left supraclavicular LN Sister Mary Joseph's Nodule - umbilical LN

Answer 19

Burning pain or discomfort - after eating at night, worsen when lying down **GERD** * Acid reflux + HB \> 2x/wk = GERD **Food Intolerance** **Esophagitis** * painful, difficulty swallowing + CP w/ eating * H. pylori or NSAIDs, or etoh **Hiatal hernia** * no sxs but can be a/w HB and abd discomfort **PUD** * burning abd pain, N/V, bloating

Answer 20

Dilated submucosal veisn in distal esophagus or proximal stomach hx of portal HTN & Cirrhosis; high mortality Sxs: * Hematemesis - coffee ground appearance * melena * VS instability * hypovolemia/tachycardia * shock Dx: * Emergent endoscopy (EGD) * **Band ligation\*\*\*\* & IV Ocreotide for vasoconstriction** * sclerotherapy * If fails - Balloon tamponade or TIPS (transjugular intrahepatitc portosystemic shunt) * Longterm - BB (propanolol), no etoh

Answer 21

Mucosal tearing of gastroesophageal junction from vomiting Sxs: * Hx of vomiting/retching or alcohol intake * **PainLESS** hematemesis Dx - Esophagogastroduodenoscopy (EGD) Tx - self limited, supportive

Answer 22

varicose vein of anus and rectum RFs - constipation/straining, pregnancy, portal HTN Dx - **Anoscopy** if BRBPR or suspected thrombosis _External_ * lower 1/3 of anus * thrombosed * significant pain, pruritis, NO bleeding * palpable perianal mass w/ purplish hue * Tx - **excision** _Internal_ * upper 1/3 of anus * BRBPR, pruritis, rectal discomfort * Tx - Fiber, sitz bath, ice packs, stool softeners * Rubber band ligation - if +protrudes, enlargement and intmt bleeding * Hemorrhoidectomy if prolapse

Answer 23

**Alpha fetoprotein (AFP)** marker esp in pst with hep C or cirrhosis **Ultrasound**, MRI lesions \>/= 1cm Liver transplant for * single lesion \< 5cm or * = 3 lesions that are all = 3cm Surgical resection - cancer can recur

Answer 24

Primary Cancer - HCC 2/2 to mets from lungs and breast Ca (MC) RFs: * Hepatitis B, C, D * Cirrhosis * Aflatoxin B1 exposure (Aspergillus spp) Sxs * Malaise, wt loss * Jaundice, ascites, Hepatosplenomegaly

Answer 25

Protrusion of organ/structure through abd wall **Inguinal hernias** * MC - through internal ring down the inguinal canal (into scrotum) **Direct inguinal hernias** * passage of intestines through external inguinal ring at Hesselbach's triangle Sxs: * Reducible bulge when patient coughs or strains * Usu painless unless 1. Incarcerated - can't be reduced 2. Obstructed - irreducible hernia but no interference w/ blood flow 3. Strangulated - blood supply cut off - bowel ischemia, necrosis perforation Tx - Open repair or lap w/ mesh reinforcement

Answer 26

**_Femoral_** - into groin at the top of inner thigh **_Incisional_** - a/w vertical incisions - esp with obesity

Answer 27

**_Sliding hernia (type 1)_** - \>90% cases, GE junction and portion of stomach herniates into thorax through esophageal hiatus (GE junction above diaphragm) **_Paraesophageal Hiatal Hernia (type 2)_** - \<5% cases . Stomach herniates into thorax through esophageal hiatus, but GE junciton does not. Remains below diaphragm. * can become strangulated Sxs * heartburn, chest pain, dysphagia Dx * Upper GI series, endoscopy Tx * Type 1 - antacid, small meals, ele of head after meal - can do Nissen fundoplication * Type 2 - elective surgery

Answer 28

Genetic +environmental factors; peaks at 15-35 yo Mouth to anus - transmural, "**Skip lesions"** Sxs: * Colicky RLQ pain * Diarrhea/ malabsorption * Low grade fever * Wt loss * a/w anal fistulas, aphthous ulcers Dx: * Colonoscopy - gold * **cobblestoning** * **skip lesions** * small bowel films * **string sign - barium study** * Lab - CBC, ESR, CRP, B-12, stool culture * **+ASCA**

Answer 29

Idiopathetic, inflammatory dz Friable **mucosa and submucosa**, limited to colon = **Rectum MC** bimodal distr - 15-25yo and 55-65 Sxs: * Bloody, pus filled diarrhea * LLQ pain * fever Dx: * Barium enema - **lead pipe appearance** * **coloscopy with bx** - gold = loss of haustral markings and lumen narrowing * risk of toxic megacolon * **pANCA**

Answer 30

Medical Management _5-Aminosalicylates ASA_ * **Mesalamine** * SE - NV, HA, rash, fever * replace folic acid * **Sulfasalazine** _Immunomodulators_ * **Azothioprine/6-mercaptopurine** * maintenance therapy * takes 3-6 mos for full effect * can come off 5ASA * check LFTs and CBC q 90 ds Biologics * TNF-inhibitors (Infliximab/Remicade, Adalimumab/Humira) * SE - reactivate of Hep B and TB (check prior to initiation) * expensive _Corticosteroids_ * high dose, short course =\> acute exacerbations * Prednisone in taper 30-40mg _Abx - for fistula_ * Metronidazole * Cipro * Rifaximin

Answer 31

Hypoperfusion to bowel vasculature Sxs: * abd pain OOP to PE * h/x of afib, vascular dz Dx - CT angio, treat in surgery

Answer 32

Bowel Obstruction - small and large Small Bowel Intussusception Ileus **_Gastroparesis_** * condition that affects stomach muscles, prevents proper emptying * MCC - DM, anorexia/bulimia, scleroderma, Ehlers-Danlos, abd surgery * N, early satiety, palps, HB, bloating * Dx - KUB, manometry, gastric emptying scan * Tx - Lower fiber and low residue diet, small meals * Metoclopramide

Answer 33

**MCC smoking\***, chronic pancreatitis, ETOH, DM, M, obesity, AA Adenocarcinoma - ductal, and **head of pancreas MC** Sxs: * MC metasis at dx - regional LN or liver * Abd pain =\> back * **painless jaundice\*** classic - 2/2 common bile duct obstruction * Wt loss * **Pruritis** - incr bile salts, **acholic stools/dark urine** * **Courvoisier's sign** - palpable, NT, distended GB a/w jaundice Dx * CT scan - initial TOC * CEA, CA 19-9 tumor markers Tx * Whipple procedure - if cancer confined to head, or duodenal area * Tail - distal resection * Advanced or inoperative * ERCP w/ palliative stent for itching

Answer 34

Cystic collection of tissue, fluid, & necrotic debris surrounding the pancreas. Wall is from **inflammatory fibrosis, not epithelial lining** a/w - chronic pancreatitis, occurs 2-3 wks after acute pancreatitis, trauma to chest (steering wheel trauma) Sxs * Abdominal pain * hx of chronic pancreatitis Dx * **CT\*\* - TOC** * US * elevated amylase/lipase * Bilirubin, CBC Tx * if persists 4-6 wks, or enlarges * Percutaneous drainage \> 5cm * Surgical decompression - **pancreaticogastrostomy** * Cystic fluid - drained into stomach or bowel

Answer 35

MCC of non hemorrhagic GI bleeds Duodenal 5x \> Gastric; MCC H pylori \> NSAIDs, ETOH, smoking Sxs: * **_Gastric Ulcers_** * abd pain worse with meals - get better after eating * patient refuses to eat (losing weight) * **_Duodenal Ulcers_** * Pain gets better with eating - worse after eating * Patient gaining weight Dx * **Endoscopy\* - gold** * UGI plain films r/o perf Tx * PPI qd-BID x 8 to 12 weeks

Answer 36

Dx * **Urea Breath test \* gold** - needs to be off PPI, bismuth and abx * active infection * urea as byproduct of metabolism * Stool antigen * Endoscopy bx Tx * Clarithromycin 500 mg BID * Amoxicillin 1g BID * PPI BID * Metronidazole 500 mg if pcn allergic * Follow up with urea breath test 1 mo post tx to ensure eradication

Answer 37

Hypertrophy and hyperplasia of muscular layers of pylorus = functional outlet obstruction Infants, first 2-3 wks of life or \< 3mos Sxs * **projectile vomiting** * **non bilious** after every feed * DeH2O - **hypochloremic, hypokalemia, metabolic alkalosis** * palpable **olive mass** in epigastric region Dx * **US - double track sign** * **Barium study - string sign** Tx * IV fluids rehydration * Pyloromyotomy - Ramstedt procedure

Answer 38

Rare, delay in dx common MC **adenocarcinoma**, highest in duodenum.; RF - hereditary nonpolyposis colorectal ca, CF, Crohns, **salt-cured food, etoh** Sxs: * Abdominal pain - intermittent and crampy * N/V, wt loss, jaundice, Anemia * Obstruction \> perforation Dx * CT * Screen for FOBT, LFTs, CBC * some +CEA Tx * Surgery - localized * Adjuvant chemo for LN+

Answer 39

Non obstructive, extreme **colonic dilation \> 6cm + signs of systemic toxicity** Eti - Crohns, UC, infection, radiation Sxs: * fever, abd pain, N/V * tenesmus * rigidity, tachycardia, dehydration, hypotension, AMS Dx * Abd radiographs - **large dilated colon \> 6cm** * 3 of the following * Fever \> 101.5 * HR \> 120 bpm * Neutrophilic leukocytosis \>10.5 x 10^9 * Anemia Tx * **bowel decompression** * Bowel Rest, NG tube, broad spectrum abx * Colostomy reserved for refractory cases

Answer 40

Bilirubin deposition = hyperbilirubinemia 1st sign - scleral icterus; serum bilirubin \> 2.5mg/dl _pathophys_ * RBC breakdown = globin + Heme =\> iron + protoporphyrin * unconjugated bilirubin +albumin -\> liver + uridine glucuronyl transferase (UGT) = conjugated bilirubin * Conjugated BR =\> bile formation in GB Eti: **Extravascular hemolysis, ineffective erythropoiesis** **Physiological jaundice of newborn** * can lead to kernicterus, neuro deficits and death = tx w/ phototherapy **Gilbert Syndrome** * mildly low UGT increases UCB = jaundice during physio stress **Crigler-Najjar Syndrome** * abs of UGT = incr UCB = kernicterus **Dubin-Johnson Syndrome** * deficiency of bilirubin canaliculi = incr CB * liver is pitch dark **Biliary Tract Obstruction** * gall stones, pancreatic carcinoma, liver fluke, cholangiocarcinoma **Viral hepatitis**