Gastrointestinal Flashcards
What is oropharyngeal dysphagia?
Problem of initiating swallowing
What is the treatment for oral HSV?
Acyclovir
What is the treatment for oral CMV?
Ganciclovir
What is the treatment for oral thrush?
Fluconazole PO and/or nystatin mouth rinses
What worsens and improves s/sx of esophageal spasms?
Worse with hot/cold foods, better with NTG
What are the typical s/sx of esophageal spasms?
Chest pain
GERD
Dysphagia
Odynophagia
What are the diagnostic test of choice for esophageal spasms? What do they reveal?
Ba swallow–Corkscrew shaped esophagus
Manometry–High amplitude, simultaneous contractions in greater than 20% of swallows
Corkscrew shaped esophagus on Ba swallow = ?
Esophageal spasm
What is the pharmacologic treatment for esophageal spasms? (3)
CCBs
TCAs
Nitrates
What is the treatment for severe esophageal spasms?
Esophageal myotomy
What is achalasia?
Impaired relaxation phase of the lower esophageal sphincter and loss of peristalsis
What is the etiologic of achalasia?
Degeneration of the inhibitory neurons in the myenteric plexus
What are the s/sx of achalasia?
Progressive dysphagia for solids and liquids
Regurgitation of food
What are the tests to diagnose achalasia?
EGD to r/o structural causes
Ba swallow
What will a Ba swallow show with achalasia?
Bird’s beak tapering of the distal esophagus
What will manometry show with achalasia?
Increased resting pressure of the LES
Incomplete LES relaxation
What is the short term pharmacologic treatment for achalasia?
Nitrates
CCBs
Endoscopic injection of botulinum toxin
What is the definitive treatment for achalasia?
Pneumatic balloon dilation or surgical myotomy
Is a Zenker diverticulum a true or false diverticulum?
False
Where does a Zenker diverticulum occur?
Through the cricopharyngeus muscle
What is the treatment for a Zenker diverticulum?
Myotomy
What is the most common type of esophageal cancer worldwide?
SCC
What is the most common type of esophageal cancer in developed nations?
Adenocarcinoma
What is SCC of the esophagus associated with?
EtOH
Smoking
Nitrosamines
Hot tea
What is the role of CT and endoscopic US in the workup of esophageal cancer?
Stagins
What is the treatment for esophageal cancer?
Chemoradiation and surgical resection
What is the prognosis for esophageal cancer in general?
Poor
Where in the esophagus does SCC vs adenocarcinoma generally occur?
SCC in the upper and middle thirds
Adenocarcinoma in the lower third
Why does esophageal cancer metastasize early?
Because the esophagus lacks a serosa
What is the cause of GERD?
Transient relaxation of the LES
True or false: GERD is a result of infection with H.Pylori
False–from relaxation of the LES
When is an EGD indicated in the workup of GERD? (3)
Refractory to medical treatment
Long standing
Associated with alarm s/sx
What is the definitive test for GERD?
24 hours pH monitoring with impedance
What is a sliding hiatal hernia?
GE junction and a portion of the stomach are displaced above the diaphragm
What is a paraesophageal hiatal hernia?
Just fundus herniates into the thorax
What are the symptoms of a hiatal hernia when symptomatic?
GERD
What is the treatment for a sliding hiatal hernia?
Medical therapy and lifestyle modifications
What is the treatment for a paraesophageal hernia?
Surgical gastropexy
What is type A chronic gastritis?
Autoantibodies to the parietal cells, causing pernicious anemia
What is type B chronic gastritis?
H/ Pylori infection
What are the s/sx of chronic gastritis, if present? (4)
Epigastric pain
N/v
Hematemesis
Melena
What are the components of triple therapy for H. pylori infection?
PPI
Amoxicillin
Clarithromycin
What are curling ulcers?
educed plasma volume leads to ischemia and cell necrosis
What are cushing ulcers?
Increased ICP causes vagal stimulation, leading to increased H+ output
What is the downside of using H/pylori antibody test for H. pylori infection?
Once infected, alway positive
A gastric adenocarcinoma that metastasizes to the ovary is called what?
Krukenberg tumor
What is the gold standard test for H. Pylori infection?
Endoscopic bx
What is the test that has both a high sensitivity and specificity for H. Pylori?
Stool antigen test
What is the only malignancy that can be cured by abx?
MALT lymphoma (from H. Pylori)
What cancer develops from chronic H. pylori infection?
MALT lymphoma
What is the most common type of gastric cancer, and what are the predisposing factors for it?
Adenocarcinoma
Diet high in nitrates and salt, low in fresh veggies
What is the definitive test for gastric cancer?
Bx
What is the treatment for gastric cancer?
Surgical resection
Very poor prognosis if metastasized
What are the two PE findings that classically suggest gastric cancer?
Virchow’s node
Sister mary joseph node
If you suspect a ulcer perforation 2/2 PUD, what study should you order?
AXR
What study should be done to r/o bleeding PUD?
Serial hematocrits
What is the treatment for an actively bleeding PUD? (4)
NG lavage
IVFs
IV PPIs
Urgent EGD
PUDs on the posterior aspect of the stomach risk which artery?
Gastroduodenal artery
How do you diagnose Zollinger-Ellison syndrome?
Increased fasting serum gastrin levels
Increased gastrin with administration of secretin
What is the treatment for Zollinger-Ellison syndrome?
high dose PPIs
Surgical resection
What drug can help patients with PUD who need an NSAID?
Misoprostol
What is the technical definition of diarrhea?
Production of more than 200g of fecal matter per day, along with liquidity of stool
What is the equation for stool osmotic gap? Normal range?
290 - 2*(Stool Na + stool K)
50-100
What are the three viruses that commonly cause pediatric diarrhea?
Rotavirus
Norwalk virus
Enterovirus
What defines chronic diarrhea?
Insidious onset over 4 weeks in duration
What are the two major, non-infectious causes of secretory diarrhea?
VIPomas
Carcinoid tumors
When does acute diarrhea warrant a further workup? (3)
Over 4-5 days
Bloody
Associated with a high fever
Watery or bloody diarrhea: Vibrio cholera
Water
Watery or bloody diarrhea: rotavirus
Watery
Watery or bloody diarrhea: Cryptosporidium
Watery
Watery or bloody diarrhea: norovirus
Watery
Watery or bloody diarrhea: Salmonella
Bloody
Watery or bloody diarrhea: Shigella
Bloody
Watery or bloody diarrhea: campylobacter
Bloody
Watery or bloody diarrhea: giardia
Watery
Low stool osmotic gap suggest what etiology of diarrhea?
Secretory diarrhea
High stool osmotic gap suggest what etiology of diarrhea?
Osmotic diarrhea
What is the most common etiology of bacterial diarrhea?
Campylobacter
What is the treatment for campylobacter diarrhea?
Supportive, then fluoroquinolones if severe
What is the abx that is often associated as the cause of C.diff?
Clindamycin
What is the major complication of C.Diff?
Toxic megacolon
Flask-shaped ulcers on endoscopy = ?
Entamoeba histolytica
Steroids + entamoeba histolytica = ?
Perforation
What is the treatment for entamoeba histolytica?
Metronidazole
What are the s/sx of entamoeba histolytica infection?
Fever and bloody diarrhea
What is the treatment for E.coli O157:H7?
Supportive–abx may precipitate HUS
What classically causes salmonella infection?
Ingestion of uncooked eggs
What are the prodromal s/sx of salmonella infection?
Abdominal pain, Fever, n/v
What complication may sickle cell patients get from a salmonella infection?
Osteomyelitis
What is the treatment for Salmonella?
IVFs
Treat bacteremia with TMP-SMX
How contagious is shigella?
Extremely
What is the treatment for shigella?
TMP-SMX
What are the complications that can arise from shigella infection?
Severe dehydration
Seizures in children
When are antidiarrheal medication contraindicated in the treatment of diarrhea?
If bloody
What are the two antibody tests for celiac disease?
IgA anti-transglutaminase or antiendomysial
In what part of the intestines are bile salt reabsorbed?
terminal ileum
Why do patients with carcinoid syndrome develop pellagra?
Tryptophan is metabolized into serotonin
Why do patients with hartnup disease develop pellagra?
Tryptophan needed to make niacin
What are the four D’s of pellagra?
Diarrhea
Dermatitis
Dementia
Death
What is the diagnostic test for lactase deficiency?
hydrogen breath test reveals increase hydrogen
Where do carcinoid tumors usually develop?
Ileum
Appendix
What are the s/sx of carcinoid tumors?
Cutaneous flushing Diarrhea Abdominal cramp Wheezing Right sided cardiac valve lesions
How do you diagnose carcinoid syndrome?
High urine levels of serotonin metabolite 5-HIAA
What is the treatment for carcinoid syndrome?
Octreotide, and surgical resection
What is the classic presentation of IBS?
Abdominal s/sx that improve with defecation
true or false: IBS s/sx usually awaken patients from sleep
False
What are the diagnostic criteria for IBS?
At least 3 days in 3 months of episodic abdominal discomfort that is:
- relieved by defecation
- associated with a change in stool frequency or consistency
- associated with a change in stool appearance
What is the dietary and pharmacologic treatment for IBS?
high fiber
SSRIs and TCAs
what are the top two causes of SBOs?
Adhesions (60%)
Hernias (15%)
What is the difference between a partial SBO vs a complete SBO
Partial still allows the passage of flatus but no stool
What are the s/sx of a SBO?
Crampy abdominal pain every 4-5 minutes
Vomiting
What are the PE findings of an SBO? (4)
Distention
TTP
hyperactive bowel sounds
High pitched tinkles and peristaltic rushes
What are the complications of an SBO?
Ischemic necrosis and/or bowel rupture
Where does the gallstone lodge in a gallstone ileus?
Ileocecal valve
Abdominal plain films in an SBO reveal what?
Stepladder pattern of dilated small bowel loops
Air fluid levels
What might a CBC show with an SBO?
Leukocytosis
What will a BMP show with an SBO?
Dehydration and metabolic alkalosis
What is the treatment for a partial SBO?
IVFs
NPO
NG suction
What is the treatment for a complete SBO?
Exploratory laparotomy
What is an ileus?
Loss of peristaltic action of the bowel, without obstruction
What are the s/sx of an ileus?
n/v
Absence of flatus or bowel movements
What will an ileus show on exam?
Diffuse TTP
Abdominal distention
Decreased or absent bowel sounds
What must be done to r/o fecal impaction in elderly patients suspected of having an ileus?
DRE
What will plain films show with an ileus?
Distended loops of small and large bowel, with air seen throughout small and large bowel
What is the treatment for an ileus?
bowel rest
NG suction
Supportive
What is the most common cause of mesenteric ischemia?
Embolism from the heart
Which vessel is most commonly affected by thrombosis in mesenteric ischemia?
SMA
What is the classic history of mesenteric ischemia?
Pain out of proportion to exam findings
How do you diagnose mesenteric ischemia?
AXR and CT
What is the classic radiographic findings of mesenteric ischemia?
Thumbprint sign and air within the bowel wall
What is the treatment for mesenteric ischemia?
IVFs
Anticoagulation
Resect infarcted bowel
What is the most common cause of acute lower GI bleed in patients over 40 yo?
Diverticulosis
Where in the bowel are most diverticula found?
Sigmoid colon
What type of diet predisposes to diverticular disease?
low fiber
High fat
What is the classic presentation of diverticulitis?
LLQ abdominal pain, fever and bleeding
Why is colonoscopy/sigmoidoscopy contraindicated in acute diverticulitis?
risk of perforation
What is the treatment for uncomplicated diverticulosis?
f/u and prescribe fiber diet
What is the treatment for bleeding diverticulitis?
Bleeding usually stops spontaneously. Surgery or colonoscopy if not
What is the treatment for acute diverticulitis?
NPO
Broad spectrum Abx
What is the treatment for a perforated bowel?
Surgery
Which has more emesis: SBO or LBO?
SBO
SBO or LBO: feculent emesis
LBO
SBO or LBO: high pitched :tinkling’ bowel sounds
Both
What is the usual etiology of SBOs?
Adhesions
What is the usual etiology of LBOs?
Neoplasms
True or false: assume the cause of a LBO is colon cancer until proven otherwise
True
What is the treatment for a SBO?
NG decompression
Surgical correction PRN
What is the treatment for a LBO?
Rectal tubes
Surgery
What enema may relieve a bowel obstruction?
Gastrografin
How are most right sided colon cancers discovered?
Anemia or occult blood
What are the s/sx of left sided colon cancer?
Apple core obstructing lesions
Pencil thin stools
Constipation/obstipation
What is the definitive way to diagnose colon cancer?
Colonoscopy
Which has a higher propensity to develop colon cancer: UC or CD?
UC
What is the order of decreasing cancer risk of colonic lesions?
Villous > tubular; sessile > pedunculated.
What is ischemic colitis? What part of the colon is usually affected?
Insufficient blood supply to the colon
Usually the watershed areas of the left colon
What are the s/sx of ischemic colitis?
Crampy lower abdominal pain, followed by bloody diarrhea
How do you diagnose Ischemic colitis?
CT w/ contrast
Colonoscopy
What will a CT show with ischemic colitis?
Thickened bowel wall,
artherosclerosis
What will a colonoscopy show with ischemic colitis?
pale mucosa with petechial bleeding
How often do patients with UC need to get colonoscopies?
every 1-2 years starting 8-10 years after diagnosis
How often do patients with first degree relatives with colon cancer need to get colonoscopies?
q5 years starting at age 40
What is the treatment for ischemic colitis?
Supportive
Surgical resection if infarcted bowel
What is the treatment for either an upper or lower GI bleed?
Protect airway
Stabilize with IVFs, and pRBCs PRN
What are the boundaries of Hesselbach’s triangle?
Inguinal ligament
Inferior epigastric artery
Rectus abdominus
What part of the colon is always involved in UC?
Rectum
Which has continuous lesions: UC or CD
UC
What is the major symptom with UC?
Bloody diarrhea
What are the major symptoms with CD?
Abdominal pain, weight loss, water diarrhea
What has the association with primary sclerosing cholangitis: CD or UC
UC
What are the oral manifestations of UC and CD?
aphthous ulcers
What are the colonoscopy findings with UC?
Pseudopolyps
What are the colonoscopy findings of CD?
Cobblestoning and skip lesions
What is the first line treatment for UC?
5-ASA agents
What is the major complication associated with UC?
Toxic megacolon
What is the curative treatment for UC?
Total proctocolectomy
What is the treatment for UC and CD flares?
Steroids
What is the classic immunomodulator for UC?
Azathioprine
What is the classic biologic used to treat UC?
Infliximab
Which has a higher incidence of associated malignancy: UC or CD?
UC
Which is more common: direct or indirect inguinal hernias?
Indirect
What is the etiology of indirect inguinal hernias?
Congenital patent processus vaginalis
What is the etiology of femoral hernias?
Increased intraabdominal pressure, weakened pelvic floor
Pigmented gallstones have what etiology?
hemolysis
Are cholesterol gallstones radiopaque or radiolucent?
Radiolucent
What are most gallstones comprised of?
Cholesterol
What is cholelithiasis?
Stones in gallbladder
What is choledocholithiasis?
Stones in the CBD
What is cholangitis?
Infection of the CBD, usually 2/2 stone
What are the s/sx of cholangitis?
RUQ TTP Fever Jaundice Shock Altered mental status
What is cholecystitis?
Inflammation of the gallbladder, typically due to stone occluding the cystic duct.
What are the s/sx of cholecystitis?
RUQ pain
Fever
Murphy’s sign
What are labs like with cholecystitis?
Leukocytosis
Normal bili, alk phos, and amylase
What are labs like with choledocholithiasis?
Leukocytosis
Increased bili
Increased Amylase
Increased alk phos
What are the labs like with cholangitis?
Increased WBC, bili, alk phos
How do you diagnose cholelithiasis?
US
How do you diagnose cholecystitis?
US, HIDA scan
How do you diagnose choledocholithiasis?
MRCP and ERCP if US negative
How do you diagnose cholangitis??
ERCP
What is the treatment for choledocholithiasis?
ERCP to remove stone, then cholecystectomy
What is the treatment for cholangitis?
ERCP, surgery if patient is toxic
What are the components of charcot’s triad?
RUQ pain
Jaundice
Fever
What are the components of Reynold’s pentad?
RUQ pain Jaundice Fever Shock Altered mental status
What are the two classic x-ray findings associated with gallstone ileus?
SBO + air in the biliary tree
What are the labs that are increased in hepatocellular injury?
AST and ALT
What are the labs that mark cholestasis?
Increased alk phos
Jaundice is present when bilirubin is above what level?
2.5 mg/dL
What are the features of fulminant liver failure?
INR more than 1.5
Hepatic encephalopathy
What happens with ALT and AST with chronic hepatitis?
Normal or only slightly elevated
What are the two inherited diseases that cause an increase in unconjugated bilirubin 2/2 defective conjugation?
Gilbert syndrome
Crigler-Najjar syndrome
What are the two inherited diseases that cause an increase in conjugated bilirubin 2/2 defective secretion?
Dubin-johnson syndrome
Rotor syndrome
What is the significance of: IgM to HAVAb?
IgM antibody to HAV; the best test to detect acute HAV.
What is the significance of: HBsAb
Immunity to HBV. If alone, then vaccinated
What is the significance of: HbcAg
Active infection
What is the significance of: HbcAb
if IgM, then current infection or window period
If IgG, then prior or current
What is the significance of: HBeAg
Infected, and transmissible
What is the significance of: HBeAb
Antibody to e antigen; indicates low transmissibility
What are the antibodies that are positive in autoimmune hepatitis?
Anti-smooth muscle
ANA
Anti-liver-kidney microsomal
Anti liver cystosol
What happens to urine Cu with Wilson’s disease?
Increased
What is the treatment for acute hepatitis?
Supportive
What is the treatment for chronic HBV infection?
Tenofovir
Entecavir
What is the treatment for HCV?
Two direct active antivirals
What is the treatment for fulminant hepatic failure?
Liver transplant
What are the histological findings of cirrhosis?
Bridging fibrosis and nodular regeneration
What is the most common etiology of cirrhosis in the US?
Chronic HCV
What are the extrahepatic causes of cirrhosis?
Biliary tract disease
Right sided heart failure
Budd-Chiari syndrome
How is spontaneous bacterial peritonitis diagnosed?
more than 250 PMNs/mL in the ascitic fluid
What are the three major labs that are used to determine the synthetic function of the liver, and what will they show in cirrhosis?
Albumin - decreased
PT/INR - increased
bilirubin - Increased
What is the equation for the serum-ascites albumin gradient?
Serum albumin - ascites albumin
What are the three major etiologies of an increased SAAG?
- Presinusoidal
- sinusoidal
- Postsinusoidal
What are the presinusoidal causes of portal HTN? (2)
Splenic or portal vein thrombosis
Schistosomiasis
What is the cause of sinusoidal portal vein HTN?
Cirrhosis
What are the three major causes of postsinusoidal portal vein HTN?
Right heart failure
Constrictive pericarditis
Budd-Chiari syndrome
What are the causes of ascites with a SAAG less than 1.1? (3)
nephrotic syndrome
TB
Malignancy
What are the components of the conservative treatment of ascites?
Na restriction
Diuretics
paracentesis
What is the definitive treatment of ascites?
TIPS
What are the s/sx of spontaneous bacterial peritonitis?
Fever
Abdominal pain
Vomiting
What is the treatment for spontaneous bacterial peritonitis?
IV abx (3rd gen cephalosporin) IV albumin
What is the prognosis of spontaneous bacterial peritonitis?
Associated with a poor 1 year prognosis
What is hepatorenal syndrome?
Acute prerenal failure 2/2 splanchnic vasodilation and decreased blood flow to the kidneys
What is the urinary Na excretion with hepatorenal syndrome?
Less than 10 mEq/mL
“healthy kidneys in an unhealthy environment”
What is the medical prophylaxis of esophageal varices?
Endoscopic surveillance with beta-blockers
What is the role of vitamin K in the setting of hepatic coagulopathy?
Will not correct it, since liver doesn’t work
Primary sclerosing cholangitis is strongly associated with what bowel disorder? Which gender is more often affected?
Ulcerative colitis
Young men
What is primary sclerosing cholangitis?
Idiopathic disorder of progressive inflammation and resulting fibrosis of the extra and intrahepatic bile ducts
Patients with primary sclerosing cholangitis are at risk for developing what malignancy?
Cholangiocarcinoma
What are the s/sx of primary sclerosing cholangitis?
Jaundice
Pruritis
Fatigue
What are the lab findings of primary sclerosing cholangitis?
- Increased alk phos
- Increased bili
What will an MRCP/ERCP show with primary sclerosing cholangitis?
Multiple bile duct strictures and dilatations (“beading”)
Liver bx of primary sclerosing cholangitis will show what characteristic finding?
onion skinning
What is the treatment for primary sclerosing cholangitis?
ERCP with dilation and stenting of strictures
Liver transplant is definitive treatment
What is primary biliary cirrhosis?
Autoimmune disease characterized by destruction of intrahepatic bile ducts
Who is most commonly affected with primary biliary cirrhosis?
Middle aged women with other autoimmune diseases
What are the lab findings of primary biliary cirrhosis?
Increase alkphos
Increased bili
What antibody is positive in primary biliary cirrhosis?
Antimitochondrial antibody
What is the treatment for primary biliary cirrhosis?
Ursodeoxycholic acid
Cholestyramine for pruritus
What is the treatment for nonalcoholic fatty liver disease?
Weight loss and exercise
What fungal food toxin is associated with hepatocellular carcinoma?
Aflatoxin
What marker can be used to help diagnose hepatocellular carcinoma?
AFP
What is the pharmacotherapy for metastatic hepatocellular carcinoma?
Sorafenib
What is the inheritance pattern and defect in primary hemochromatosis?
AR mutation in HFE gene
What happens to the following lab values with hemochromatosis:
- Serum Fe
- % sat Fe
- Ferritin
- Transferrin
- Serum Fe increased
- % sat Fe increased
- Ferritin increased
- Transferrin DEcreased
What is the treatment for hemochromatosis , regardless of etiology?
Weekly phlebotomy
Deferoxamine
When do patients with Wilson’s disease usually present?
Before age 30
What is the treatment for Wilson’s disease?
Penicillamine or trientine
Diet Cu restriction
The hallmark PE finding of pancreatic cancer is what?
Nontender palpable gallbladder with jaundice
What are the s/sx of a VIPoma? Stool osmotic gap?
Watery diarrhea
Low stool osmotic gap
Why is there achlorhydria in a VIPoma?
VIP inhibits gastrin production
What is Courvoisier sign?
nontender gallbladder (pancreatic cancer)
What is Trousseau sign?
Migratory thrombophlebitis (pancreatic cancer)
What are the typical s/sx of chronic pancreatitis?
Steatorrhea and epigastric pain
What are the CT findings of chronic pancreatitis?
“chain of lakes”
alternating stenosis and dilation of the main pancreatic duct
What is the treatment for acute pancreatitis?
IVFs
bowel rest
NG suction
What is the treatment for chronic pancreatitis?
Pancreatic enzyme replacement
endoscopic dilation of ducts
What are the two major complications of acute pancreatitis?
Fistula formation
Pseudocyst formation
What is the tumor marker for pancreatic cancer?
CA19-9
What are the CT findings of chronic pancreatitis?
Calcifications and dilated ducts
What is the chemotherapy for pancreatic cancer?
5-Fu
