Gastrointestinal Flashcards
1
Q
What antibodies are seen in autoimmune hepatitis?
A
Type I + ANA, smooth muscle antibodies
Type II anti liver/kidney microsomal antibodies
2
Q
What is the txt for autoimmune hepatits?
A
corticosteroids + Azathioprine
3
Q
What unusual side effect is seen in acute viral hepatitis?
A
decreased desire to smoke
4
Q
What two phases are seen in acute viral hepatitis?
A
icteric- jaundice
fulminant- encephalopathy, coagulopathy
5
Q
Txt for viral hepatitis?
A
clinical recovery 3-16wks
6
Q
What is the MC cause of fulminant hepatitis?
A
acetaminophen toxicity
7
Q
What is the definitive txt for fulminant hepatitis?
A
Liver transplant
8
Q
What is the txt for fulminant hepatitis?
A
supportive
9
Q
What are the two manifestations seen in fulminant hepatitis?
A
encephalopathy & coagulopathy
10
Q
Transmission of Hep A and Hep E?
A
fecal-oral
11
Q
What symptom is associated w/ Hep A?
A
spiking fever
12
Q
Txt for Hep A?
A
none
13
Q
T/F Fulminant hepatitis is rare in Hep A?
A
true
14
Q
What is the best way to prevent Hep A and Hep B?
A
Handwashing & improved sanitation
15
Q
Who should get Hep A pre-exposure prophylaxis?
A
increased risk of HAV and international travelers
16
Q
What is the prophylaxis for post-exposure Hep A?
A
Healthy 1-40yr= HAV vaccine
Healthy > 40= HAV vaccine +/- HAV IVIG
Immunocomp= HAV vaccine + HAV IVIG
17
Q
When should post-exposure Hep A vaccine be admin?
A
within 2 wks of exposure
18
Q
What is seen on PE for Hep A?
A
jaundice, hepatomegaly, splenomegaly, rash, arthralgia, pruritus
19
Q
Who’s at risk for Hep A exposure?
A
close contact w/ infected, day care workers, men sex men, homelessness, shellfish, illicit drug use.
20
Q
T/F Hep E can be transmitted mother-child?
A
True
21
Q
Who is at an increase risk of fulminant Hep E?
A
pregnant women, malnourished
22
Q
Txt for Hep E?
A
none
23
Q
Who has the highest mortality in Hep E infection?
A
fulminant hepatitis during pregnancy
24
Q
Transmission of Hep B and E?
A
percutaneous, sexual, parenteral, perianatal
25
Txt for Hep B?
supportive
26
Vaccine for Hep B?
recombinant Hep B vaccine
27
What ages do infants get Hep B vaccine?
birth, 1-2 mo and 6-18mo
28
What antigen appears first in Hep B infection?
HBsAg (surface antigen)
29
1st evidence of infection w/ Hep B?
Anti-HBs
30
1st evidence of diagnosis of Hep B?
AB-IgM
31
Which antigen indicates viral replication and infection in Hep B?
HBeAg
32
What does Hep D need to survive?
HBsAg
33
How is Hep D transmissed?
parenteral
34
How can you prevent Hep D?
Hep B vaccination
35
How is Hep D screened for?
HDV RNA in serum
36
Which hepatitis virus has the highest morbidity?
Hep D
37
Which hepatitis virus has the highest rate of chronicity?
Hep C
38
MC infectious cause of liver dx, cirrhosis, and liver transplantation in the US?
Hep C
39
MC cause of Hep C transmission?
IV drug use
40
Screening test of Hep C?
HCV antibodies
41
Confirmatory test for Hep C?
HCV RNA
42
Txt for HCV?
lots of new antivirals
43
What should be checked before txt HCV?
HBV testing (due to reactivation)
44
If left untreated what is the prognosis for HCV?
hepatocellular cancer
45
Which type of Hepatitis is associated with a high infant mortality rate in pregnant women?
Hep E
46
Txt for hepatic cancer?
surgical resection if confined to a lobe and not assoc/ w/ cirrhosis
47
How is hepatic cancer screened for?
ultrasound q 6 mo w/wo AFP
48
Tumor marker hepatic cancer?
Alpha fetoprotein
49
Whom should be screened for HCC?
- active HBV infection
| - high risk pts
50
MC cause of cirrhosis?
Chronic Hep C
51
2nd MC cause of cirrhosis?
alcohol
52
What vaccination can be given to txt cirrhosis
Hep A and Hep B
53
What is the definitive txt for cirrhosis?
liver transplant
54
What is the screening recommendation for cirrhosis?
ultrasound q 6 mo w/wo AFP
55
What is the txt for encephalopathy due to cirrhosis?
Lactulose or Rifaximin. Neomycin 2nd line
56
What is the txt for ascites due to cirrhosis?
Diuretics (Spironolactone, Furosemide) Paracentesis
57
What is the txt for pruritus due to cirrhosis?
cholestyramine
58
Classification system is used to stage cirrhosis?
Child-Pugh
59
MC cause of acute pancreatitis?
gallstones and etoh
60
Symptoms of acute pancreatitis?
boring pain radiates to back, n/v, fever, pain while supine and relieved w/ leaning forward
61
What is cullen's sign?
periumblical ecchymosis
62
What is Grey Turner sign?
flank ecchymosis
63
What are the 3 diagnosis criteria for acute pancreatitis?
- acute persistent severe epigastric pain
- elevation in serum lipase or amylase x3
- findings on CT, MRI, US
64
What are the best initial test for acute pancreatitis?
amylase and lipase (best)
65
What electrolyte abnormalities is found acute pancreatitis?
hypocalcemia
66
DOC for acute pancreatitits?
abdominal CT
67
Txt for acute pancreatitis?
NPO, IV fluids, analgesia
68
What criteria is used to determine prognosis of pancreatitits?
Ransons criteria
69
MC cause of chronic pancreatitis?
Alcohol
70
What is the triad of chronic pancreatitis?
calcifications, steatorrhea, DM
71
Are amylase and lipase elevated in chronic pancreatitis?
No, normal
72
What pancreatic function test is the most sensitive and specific for chronic pancreatitis?
fecal elastase
73
Txt for chronic pancreatitis?
etoh abstinence, pain control, low fat diet, vitamin supplementation, oral pancreatic enzyme replacement
74
Txt for retractable pain in chronic pancreatitis?
Pancreatectomy
75
Which of the following abnormalities is this plain film most likely to show in acute pancreatitis?
sentinel lopp
| colon cutoff sign
76
MC organism in rectal abscess?
Staph aureus
77
MC site of fistula?
posterior rectal wall
78
Txt for rectal abscess?
I&D
79
Supportive txt after I&D for rectal abscess?
W- warm water cleanse
A-analgesics
S- sitz baths
H- high fiber diet
80
Txt for fistula?
fistulotomy
81
Where are anal fissures commonly found?
distal anal canal in POSTERIOR midline
82
What type of tear is seen in anal fissure?
longitudinal tear
83
1st line txt for anal fissure?
supportive (warm water, stool softeners, laxatives, mineral oil)
84
2nd line txt for anal fissure?
topical vasodilators: nitroglycerin, Dilitazem, Nifedipine ointment
85
What is the txt for refractory anal fissure?
lateral internal sphincterotomy
86
What is a anal fistula?
open tract between two epithelium lined areas
87
What is celiac disease?
autoimmune mediated inflammation of the small bowel due to reaction w/ alpha-gliadin found in gluten food
88
MC symptom of celiac?
diarrhea
89
Rash seen in celiac disease?
dermatitis herpetiformis
90
What is the best screening for celiac disease?
symptom improvement w/ trial of gluten-free diet
91
What screening can be done to identify celiac dx?
transglutaminase IgA antibodies
92
What is the definitive dx of celiac dx?
small bowel biospy
93
What is found on biopsy for celiac dx?
atrophy of the vili
94
Txt for celiac disease?
avoid wheat, rye, barley
95
What supplementation is needed in celiac dx?
vitamin
96
What area of the bowel is MC in crohn disease?
terminal ileum
97
What symptoms are seen in crohn dx?
ileocolitis- RUQ, diarrhea (not bloody), weight loss
98
Initial test of choice in crohn dx?
upper GI series
99
String sign is seen in what dx?
Crohn dx
100
What is seen on endoscopy of crohn dx?
segmental "skip areas", cobblestoning, strictures, aphthous ulceration
101
What antibodies are seen in Crohn dx?
anti-saccharomyces cerevisiae antibodies
102
What vitamin deficiency is seen in crohn dx?
B12
103
Txt for Crohn?
5-SA or oral glucocorticoids
104
What symptoms are seen in UC?
diarrhea (bloody), crampy abdominal pain, tenesmus
105
What is seen on barium enema on UC?
stovepipe or lead pipe sign
106
What antibodies are seen in UC?
positive P-ANCA
107
Txt for UC?
topical 5 aminosalicylic acid (ASA)
108
What is the definitive curative txt of UC?
surgical resection (colectomy)
109
After 8yrs of being dx with UC what should be done?
colonoscopy q 1yr
110
What can UC turn into?
colorectal cancer
111
What should be monitor frequently with Methotrexate txt?
CBC and LFT
112
MC area for UC?
rectum
113
Smoking decreases risk for?
UC
114
What are the 3 patho of IBS?
Abnormal motility
Visceral hypersensitivity
Psychosocial interactions
115
What is the hallmark sx of IBS?
abdominal pain associated w/ altered defecation/ bowel habits. Pain relieved w/ defecation
116
What criteria is used in IBS?
Rome
117
How is IBS dx?
dx of exclusion
118
What is rome criteria?
recurrent abdominal pain at least 1 day/wk in the last 3 mo associated w/ 2:
1. related to defecation
2. onset w/ change in stool frequency
3. onset w/ change in stool appearance
119
1st line txt for IBS?
lifestyle and dietary change (low fat, high fiber, unprocessed food diet)
120
Txt for constipation?
fiber, psyllium
121
Txt for diarrhea?
loperamide
122
Infection associated with an increased prevalence of IBS
Giardia lambila
123
What area of the colon is most affected in diverticulosis?
right
124
MC cause of acute lower GI bleeding?
diverticulosis
125
TOC for diverticulosis?
colonoscopy
126
What is both diagnostic and therapeutic for diverticulosis?
colonoscopy
127
Txt for diverticulosis?
IV fluids, bleeding stops spontaenously
128
Txt for asymptomatic diverticulosis?
high fiber diet, bran, psyllium
129
MC area for diverticulitis?
sigmoid colon
130
Sx of diverticulitis?
LLQ pain, low grade fever, tender mass
131
TOC for diverticultis?
abdominal CT
132
Why isn't a colonoscopy or barium enema performed in diverticulitis?
perforation risk
133
Txt for diverticulitis?
outpt oral antibodies (Metronidazole + Fluroqu) for 7-10days and clear liquid diet
134
Alternative abx txt for diverticulitis?
Bactrim + Metronidazole
135
Refractory txt for diverticulitis?
surgery
136
Criteria for admission of complicated diverticulitis?
abscess >3cm
137
Criteria for admission of uncomplicated diverticulitis?
fever, sepsis, immunosuppression, increased age, intolerant to oral intake
138
Where do most colorectal cancers arise from?
adenomatous polyps
139
What Inflammatory bowel disease can lead to colon cancer?
Ulcerative colitis
140
Txt for familial adenomatous polyposis?
prophylactic colectomy
141
MC cause of large bowel obstruction in adults?
cancer
142
What bleeding deficiency is seen in colon cancer?
iron deficiency anemia
143
TOC for colorectal cancer?
colonoscopy w/ biopsy
144
What filling defect is seen on barium enema for colon cancer?
apple core lesion
145
What is the tumor marker for colon cancer?
CEA
146
Txt for localized colon cancer?
resection followed by post op chemotherapy
147
Txt for metastatic colon cancer?
palliative chemotherapy (w/ 5FU/ Fluorouracil)
148
Screening for colon cancer?
fecal occult blood test annually at 50y or 40yr or 10yr prior to relative
+
colonoscopy every 10yrs (or flex sigm q5y)
or 1st degree > 60 q 10yrs or <60y q 5y
149
What age does colon cancer screening stop?
75yr
150
If a pt had familial adenomatous polyposis when does screening start?
age 10-12 w/ flexible sigmoidoscopy yearly
151
If a patient had lynch syndrome when does screening start?
age 20-25 w/ colonoscopy q 1-2yrs
152
MC type of esophageal cancer in the US?
Adenocarcinoma
153
MC type of esophageal cancer in the world?
squamous cell
154
Who is at an increase risk for esophageal adenocarcinoma?
younger patients, white males
155
Who is at an increase risk for esophageal squamous cell cancer?
50-70yr, African Americans
156
Where is esophageal adenocarcinoma most commonly located?
distal esophagus
157
Where is esophageal squamous cell most commonly located?
mid to upper third of esophagus
158
What is a major risk of esophageal adenocarcinoma?
Barrett's esophagus, smoking, high body mass
159
What is a major risk of esophageal squamous cell?
smoking & alcohol
160
What two things may have protective effects on esophageal cancer, particularly in the setting of barrett's esophagus?
Aspirin or NSAIDS
161
Hallmark of esophagus cancer?
solid food dysphagia progressing to include fluids (odynophagia)
162
What electrolyte problem is seen in esophageal squamous cell cancer?
hypercalcemia
163
DOC for esophageal cancer?
upper endoscopy w/ biopsy
164
What is used to stage esophageal cancer?
endoscopic ultrasound
165
Txt for esophageal cancer?
esophageal resection w/ chemotherapy
166
MC type of gastric cancer?
Adenocarcinoma
167
The biggest risk factor for gastric cancer?
H.pylori
168
What dietary types puts someone at an increase risk for gastric carcinoma?
preserved foods
169
Sx of gastric carcinoma?
weight loss, persistent abdominal pain, early satiety
170
TOC for gastric carcinoma?
upper endoscopy w/ biopsy
171
Tt for gastric cancer?
endoscopic resection
| gastrectomy, chemotherapy
172
What is the prognosis for gastric and esophageal cancer?
poor prognosis
173
Screening for barretts esophagus?
endoscopy q 3-5yrs
174
Supraclavicular lymph node seen in gastric cancer?
Virchow's node
175
MC cause of acute cholecystitis?
E.coli
176
Sx of acute cholecystitis?
continuous RUQ or epigastric pain precipitated by fatty foods or large meals.
177
What is Murphy's sign?
RUQ pain or inspiratory arrest w/ palpation of the gallbladder
178
What is Boas sign?
referred pain to the right shoulder or subscapular area
179
What is the initial TOC for gallstones?
ultrasound
180
What is the most accurate test for acute cholecystitis?
HIDA scan
181
Txt for acute cholecystitis?
NPO, IV fluids, abx, cholecystectomy
182
When should a cholecystectomy be performed in cholecystitis?
within 72hrs
183
What meds are used in cholecystitis?
Ceftriaxone + Metronidazole
184
Charcot's triad?
fever, chills, RUQ pain + jaundice
185
Reynold pentad?
charcot's + hypotension + altered mental status
186
Most accurate imaging test for acute cholangitis?
MRCP
187
Gold standard txt for acute cholangitis?
ERCP
188
Txt for acute cholangitis?
IV abx + ERCP
189
If pt is unable to do ERCP what should be performed?
percutaneous transhepatic cholangiogram
190
Definitive txt for gallstones?
elective cholecystetomy
191
MC gallstone?
cholesterol (mixed)
192
Risk factors for cholelithiasis?
5Fs- fat, fair, female, forty, fertile
193
Sx of cholelthiasis?
biliary colic "episodic" abrupt RUQ pain, nausea, precipitated by fatty foods or large meals
194
Txt for cholelithiasis?
observation
Ursodeoxycholic acid
elective cholecystectomy
195
What is Cholelithiasis?
gallstones in the biliary tract WITHOUT inflammation
196
What is Choledocholithiasis?
gallstones in the common bile duct
197
Sx of Choledocholithiasis?
PROLONGED biliary colic
198
DOC for Choledocholithiasis?
ERCP
199
Txt for choledocholithiasis?
ERCP
200
What is Linitis plastica?
diffuse thickening of the stomach wall due to cancer infiltration
201
DOC for esophageal stricture?
barium swallow esophagram
202
TOC for esophageal stricture?
endoscopic dilation
203
Where are esophageal webs usually located?
mid-upper esophagus
204
Where are esophageal shatzki rings located?
lower esophagus (squamocolumnar junction)
205
Most pts with shatzki rings also have?
hiatal hernia
206
What is steakhouse syndrome?
bolus of food that gets stuck in the lower esophagus
207
Sx seen in shatzki rings?
episodic dysphagia to solids
208
Circumferential diaphragm of tissue that protrudes into the esophageal lumen?
esophageal shatzki ring
209
Non-circumferential thin membrane in the mid-upper esophagus?
esophageal web
210
What can decrease the recurrence of esophageal web?
PPI
211
Dysphagia + cervical esophageal webs + iron deficiency anemia + atrophic glossitis?
Plummer Vinson Syndrome
212
Plummer Vinson Syndrome puts you at risk for what?
esophageal squamous cell carcinoma
213
Characteristics of internal hemmorhoids?
tend to bleed and are painless
214
Characteristics of external hemorrhoids?
tend to not bleed and are painful
215
Stage I hemorrhoids?
does not prolapse (confined to anal canal). May bleed w/ defecation
216
Stage II hemorrhoids?
prolapses with defection, but spontaneously reduce
217
Stage III hemorrhoids?
prolapses w/ defection, requires manual reduction
218
Stage IV hemorrhoids?
irreducible and may strangulate
219
Tend palpable anal mass?
external hemorrhoids
220
How do you diagnosis internal hemorrhoids?
anoscopy
221
Txt for hemorrhoids?
conservative txt high fiber diet, increase fluids, warm sitz bath
222
Txt for failed conservative txt for hemorrhoids?
rubber band ligation
223
Txt for stage IV hemorrhoids?
hemorrhoidectomy
224
How do you dx hemorrhoids?
visual inspection
225
Definitive txt for internal hemorrhoids?
band ligation
226
Definitive txt for external hemorrhoids
excision
227
Type of anal cancer?
squamous cell
228
Txt for anal cancer?
chemo + rad
229
MC cause of esophageal varices?
cirrhosis
230
Sx of esophageal varices?
hematemesis, melena, hematochezia
231
TOC for esophageal varices?
upper endoscopy
232
Initial TOC for esophageal varices?
endoscopic variceal ligation
233
What should be done first for a pt with esophageal varices?
stabilize: 2 large bore IV lines, IV fluids
234
1st line medical management for esophageal varices?
Octreotide
235
Mechanism of octreotide?
somatostatin analog that causes vasoconstriction of the portal venous flow
236
If octreotide txt fails what is 2nd line txt?
Vasopressin
237
Txt for a patient active rapid esophageal varices bleed?
ballon tamponade
238
Definitive txt for esophageal varices?
TIPS (transjugular intrahepatic portosystem shunt)
239
abx prophylaxis for esophageal varices?
fluoroquinolones or Ceftriaxone
240
Txt for prevention of rebleed in esophageal varices?
non-selective beta blockers (propranolol)
241
what percentage of esophageal varices rebleeds are fatal?
1/3
242
MC cause of esophagitis?
GERD
243
What are the 3 findings in esophagitis?
odynophagia, dysphagia, retrosternal chest pain
244
Dx for esophagitis?
upper endoscopy
245
MC cause for infectious esophagitis?
Candida
246
Linear yellow white plaques on endoscopy?
candida
247
large superficial shallow ulcers on endoscopy?
CMV
248
small, deep ulcers on endoscopy?
HSV
249
Txt for candida esophagitis?
PO flucanazole
250
Txt for CMV esophagitis?
Ganciclovir
251
Txt for HSV esophagitis?
Acyclovir
252
eosinophilic esophagitis is most commonly seen in what?
atopic disease (Asthma, Eczema)
253
Sx of eosinophilic esophagitis?
dysphagia (especially solids)
254
What is seen on endoscopy for eosinophilic esophagitis?
multiple corrugated rings
255
Txt for eosinophilic esophagitis?
remove offending agent, inhaled topical corticosteroids w/o spacer
256
MC cause of gastritis?
H. plyori
257
2nd MC cause of gastritis?
NSAIDS and Aspirin
258
DOC for gastritis?
upper endoscopy w/ biospy
259
Txt for gastritis?
H2 receptor, PPI
260
Prophylaxis for pts at high risk for developing stress related gastritis?
IV PPI or H2 blockers
261
What is the MOA for GERD?
transient relaxation of the LES
262
Hallmark sx for GERD?
heartburn (pyrosis)
263
Gold standard Dx of GERD?
24 HR ambulatory pH monitoring
264
Dx for persistent or complicated GERD?
endoscopy
265
Txt for GERD?
conservative txt, H2 blockers, PPI
266
Txt for <2episodes/wk of GERD?
H2 blockers
267
Txt for >2episodes/wk of GERD?
PPI
268
Txt for pts refractory to PPI txt?
Nissen fundoplication
269
MC type of hiatal hernia?
Type I sliding
270
Txt for sliding hiatal hernia?
PPI + weight loss
271
Txt for paraesophageal hiatal hernia?
surgical repair
272
Can occur after persistent retching or vomiting after ETOH binge?
Mallory Weiss syndrome
273
TOC for mallory weiss syndrome?
upper endoscopy
274
Superficial longitudinal mucosal laceration?
Mallory Weiss syndrome
275
Txt for non active mallory weiss tear?
supportive (PPI)
276
Txt for active mallory weiss tear?
hemo clips, endoscopic banding, ballon tamponade
277
MC peptic ulcer?
duodenal ulcer
278
gastric ulcers are usually associated with?
gastric adenocarcinoma
279
Patho of duodenal ulcers?
increased aggressive factors (H.plyori)
280
Patho of gastric ulcers?
decreased protective factors (bicarb)
281
Hallmark of peptic ulcer?
dyspepsia (burning, gnawing, epigastric pain)
282
Ulcer that is classically relieved w/ food?
duodenal
283
Ulcer that hates food?
gastric
284
MC cause of upper GI bleed?
peptic ulcer
285
DOC for peptic ulcer?
upper endoscopy
286
All gastric ulcers need what?
repeat upper endoscopy to document healing
287
Test used to dx H.pylori and confirm eradication after therapy?
H. pylori stool antigen
288
Triple therapy for peptic ulcer?
Clarithromycin + Amoxicillin (Metronidazole) + PPI
289
Quad therapy for peptic ulcer?
Bismuth subsalicylate + Tetracycline + Metronidazole + PPI
290
Txt for pts refractory to peptic ulcer txt?
```
parietal cell vagotomy
Bilroth II (dumping syndrome)
```
291
gastric ulcers can turn into?
cancer
292
MOA for PPI?
block H+/K+ ATP-ase of parietal cell reducing acid
293
Electrolyte abnormalities sde of PPI?
B12 deficiency, hypomag, hypocalcemia
294
MC cause of gastroenteritis in adults in N. America?
Norovirus gastroenteritis
295
MC cause of viral gastroenteritis worldwide?
Norovirus gastroenteritis
296
Infectious diarrhea associated with outbreaks on cruise ships, hospitals, resturants?
norovirus
297
Predominant sx of norovirus?
vomiting
298
Txt for norovirus gastroenteritis?
fluid replacement
299
Mc cause of diarrhea in young unimmunized children?
rotavirus
300
Gastroenteritis from diary products, mayonnaise, meats, eggs, salads?
Staph aureus gastroenteritis
301
Predominant sx of staph gastroenteritis?
Vomiting and nausea
302
MC cause of traveler's diarrhea?
enterotoxigenic e.coli
303
Predominant sx of enterotoxigenic e.coli?
abrupt onset of watery non-bloody diarrhea
304
Diarrhea from poor sanitation & overcrowding conditions?
vibrio cholerae
305
Predominant sx of vibrio cholerae?
"rice water stools", fishy odor
306
Txt for vibrio cholerae?
oral rehydration and electrolyte replacement
307
1st line abx therapy for vibrio cholerae?
Tetracyclines
308
Txt for c. difficle?
oral vancomycin or oral Fidaxomicin
309
Diarrhea primarily after a course of Clindamycin, advance age, PPI use?
C. difficile
310
What type of meds do you NOT give in invasive diarrhea?
anti-motility drugs
311
Consumption of raw or undercooked poultry can cause?
C. jejuni
312
Predominant sx of campylobacter enteritis?
diarrhea initially watery progressing to bloody
313
Txt of c. jejuni?
fluids, macrolides (Azithromycin)
314
MC cause of foodborne dx in US from poultry, eggs, milk, reptitles?
Salmonella
315
Txt for salmonella?
rehydration, fluoroquinolones
316
Explosive watery diarrhea that progresses to mucoid & bloody diarrhea?
Shigellosis
317
Txt for Shigellosis?
oral rehydration
318
Backpacker's diarrhea?
Giardia lamblia
319
Frothy, greasy, foul smelling diarrhea?
Giardia lamblia
