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Internal Medicine > Gastrointestinal Step Up > Flashcards

Gastrointestinal Step Up Flashcards

1
Q

what do you do if a patient has a positive FOBT? even if they are asymptomatic?

A

colonscopy

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2
Q

most sensitive and specific test for colon cancer

A

colonscopy

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3
Q

what test is complementary to flexible sigmoidoscopy in evaluating CRC?

A

barium enema

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4
Q

what is CEA useful for?

A

NOT SCREENING

- used for baseline and recurrence surveillance

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5
Q

what pre-op value of CEA implies worse prognosis in CRC?

A

> 5 ng/mL

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6
Q

what type of polyps have the highest malignant potential?

A

villous adenomas (Vs. tubular adenomas)

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7
Q

polyps plus osteomas, dental abnormalities, benign soft tissue tumors, desmoid tumors and/or sebaceous cysts

A

Gardner’s syndrome

- risk of CRC is 100% by age 40

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8
Q

polyps plus cerebellar medulloblastoma or glioblastoma multiforme

A

Turcot’s syndrome

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9
Q

multiple hamartomas throughout entire GI tract and pigmented spots around oral mucosa, lips and genitalia

A

Peutz-Jegher’s syndrome

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10
Q

Lynch syndrome I

A

site specific CRC - early onset CRC

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11
Q

Amsterdam Criteria I

A

for dx. Lynch syndrome

  • atleast 3 relatives with CRC (one first degree)
  • 2+ generations
  • one onset before age 50
  • FAP has been excluded
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12
Q

Lynch syndrome II

A

early onset CRC plus other cancers (breast, endometrial ca, skin, stomach, pancreas, brain etc)

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13
Q

MCC of large bowel obstruction in adults

A

CRC

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14
Q

MC presenting symptom in CRC

A

abdominal pain

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15
Q

pt suspected of having CRC presents with anemia, weakness, occult blood in stool, melena, and iron deficiency anemia - where is the tumor likely located?

A

right sided tumors i.e. cecum

- lack of obstructive symptoms

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16
Q

pt suspected of having CRC presents with alternating constipation and diarrhea; he also has hematochezia - where is the tumor likely located?

A

left sided tumor

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17
Q

MC symptoms of rectal cancer

A

hematochezia with tenesmus and incomplete feeling of evacuation due to rectal mass

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18
Q

in what case of CRC is radiation therapy indicated?

A

rectal cancer

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19
Q

follow-up of CRC after resection includes? (4)

A
  1. stool guaic test
  2. annual CT scan of abdo/pelvis and CXR for 5 years
  3. colonscopy at 1 year and then every 3 years
  4. CEA levels
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20
Q

MC non-neoplastic polyps

A

hyperplastic (metaplastic) polyps

- commonly removed even though they are benign

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21
Q

MC type of neoplastic polyp

A

tubular adenoma

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22
Q

at what size is there greater risk of malignant potential in a colon polyp?

A

> 2.5 cm

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23
Q

what shape of polyp is most likely to be malignant

A

sessile (vs. pedunculated)

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24
Q

MC location of diverticulosis

A

sigmoid colon

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25
Q

test of choice for diagnosing diverticulosis

A

barium enema

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26
Q

tx. of diverticulosis

A

high-fiber diet (bran) to increase stool bulk

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27
Q

complications of diverticulosis

A

painless rectal bleeding

diverticulitis

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28
Q

how do you manage painless rectal bleeding as a complication of diverticulosis

A

usually stops on its own
colonscopy - to locate site of bleeding
if bleeding persists or recurs - consider segmental colectomy

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29
Q

pt presents with fever, LLQ and leukocytosis; you find inflammation of pericolic fat, bowel wall thickening and pericolic fluid collection - what should you consider?

A

diverticulitis

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30
Q

complications of diverticulitis

A

abscess formation - drained surgically
colovesical fistula
obstruction
colonic perforation - peritonitis

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31
Q

Dx. test of choice in diverticulitis

A

CT scan w/ oral and IV contrast

- avoid barium enema and colonscopy due to risk of perforation

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32
Q

Tx. of uncomplicated diverticulitis

A

IV antibiotics, bowel rest (NPO) and IV fluids

- if sx persist for 3-4 days, may need to consider surgery

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33
Q

Tx. of complicated diverticulitis

A

surgery - resection of involved segment

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34
Q

tortuous, dilated veins in the submucosa of the proximal wall of colon

A

Angiodysplasia of colon

- aka. AV malformation or vascular ectasia

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35
Q

MC sx. of angiodysplasia of colon

A

lower GI bleeding - usually stops on its own

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36
Q

Dx. of angiodyplasia

A

colonoscopy - preferred over angiography

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37
Q

Tx. of angiodysplasia of colon

A

usually not needed

  • colonscopy coagulation of lesion if frequent bleeding
  • right hemicolectomy if persistent bleeding
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38
Q

what condition is angiodysplasia (oddly) associated with?

A

aortic stenosis

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39
Q

four “causes” of acute mesenteric ischemia

A

arterial embolism
arterial thrombosis
non-occlusive mesenteric ischemia
venous thrombosis

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40
Q

pt presents with acute onset, severe abdominal pain; abdominal exam is benign - what test(s) should you order in order to get a diagnosis?

A

check lactate level
plain films - R/O other causes of pain
mesenteric angiography - test of choice for acute mesenteric ischemia

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41
Q

what classic finding can be seen on XR/barium enema in ischemic colitis?

A

thumb-printing (due to thickened edematous mucosal folds)

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42
Q

Tx. of choice for arterial causes of acute mesenteric ischemia

A

direct intra-arterial infusion of papaverine (vasodilator) into SMA during arteriography

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43
Q

what drugs should be avoided in mesenteric ischemia?

A

vasopressors

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44
Q

older patient presents with dull abdominal pain classicaly following every meal; there has been significant weight loss (bc the patient now seems to be avoided eating) - what test do you order to confirm your diagnosis?

A

chronic mesenteric ischemia

- order mesenteric angiography

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45
Q

Tx. of chronic mesenteric ischemia

A

surgical revascularization

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46
Q

patient presents with signs and symptoms of large bowel obstruction; radiographic imaging confirms this - however, there is no actual mechanical obstruction - dx?

A

Ogilvie’s syndrome

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47
Q

what is the sign of impending bowel rupture?

A

colonic distention with diameter > 10 cm

- you need to decompress immediately

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48
Q

patient who was recently tx. with clindamycin develops profuse watery diarrhea and crampy abdominal pain - dx?

A

pseudomembranous colitis

- usually occurs after course of ampicillin, clindamycin or cephalosporing antibiotics

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49
Q

how do you confirm diagnosis of pseudomembranous colitis?

A

C.difficle toxin in stool

abdominal XR to r/o complications

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50
Q

DOC for pseudomembranous colitis

A 
oral metronidazole (can also be given IV)
- if this does not work, try oral vancomycin
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51
Q

what drug can be used as adjuvant tx. to improve the diarrhea associated with pseudomembranous colitis?

A

cholestyramine

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52
Q

twisting of loop of intestine around its mesenteric attachment site, most commonly in the sigmoid colon

A

colonic volvulus

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53
Q

RFs for colonic volvulus

A 
chronic illness
age
institutionalization
CNS disease
chronic constipation/antimotility drugs
laxative abuse
prior abdominal surgery
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54
Q

plain film findings in

  • sigmoid volvulus (1)
  • cecal volvulus (2)
A

(1) omega loop sign - indicates dilated sigmoid colon

(2) distention of cecum/small bowel; coffee bean sign indicating large air-fluid level in RLQ

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55
Q

preferred diagnostic test for sigmoid volvulus

A

sigmoidoscopy - it also usually successfully decompresses and untwists it leading to tx. as well - but these commonly recur, so you should offer your patient an elective sigmoid resection

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56
Q

what is used to measure disease severity in liver cirrhosis and serves as a predictor of morbidity/mortality?

A 
Child's classification
- class A is mild disease; class C is severe dz
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57
Q

MCC of cirrhosis

A

alcoholic liver dz

chronic viral infection - hepC

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58
Q

gold standard test for diagnosis of liver cirrhosis

A

liver biopsy

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59
Q

how can you lower portal HTN?

A

transjugular intrahepatic portal-systemic shunts (TIPS)

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60
Q

how do you tx. someone with perforated esophageal varices?

A
  1. IV fluids - stabilize BP
  2. IV octreotide - 3-5 days
  3. upper GI endoscopy with variceal ligation/banding or sclerotherapy
  4. IV antibiotics prophylactically
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61
Q

how do you prevent rebleeding in someone with esophageal varices?

A

tx. with non-selective B-blockers

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62
Q

what tests should be done in suspected ascites?

A

abdominal USG - can detect as little as 30 ml fluid

paracentesis

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63
Q

indications for paracentesis

A

new onset ascites
worsening ascites
suspected spontaneous bacterial peritonitis

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64
Q

serum ascites-albumin gradient

A

if > 1.1 g/dL = portal HTN

if < 1.1 g/dL = must consider other causes of ascites

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65
Q

step-wise tx. of ascites

A
  1. Na+ and water restriction
  2. spironolactone
  3. furosemide - not > 1L/day
  4. therapeutic paracentesis
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66
Q

what test should patients with cirrhosis have done?

A

endoscopy to assess for presence of esophageal varices - if present, tx. with B-blocker

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67
Q

precipitants of hepatic encephalopathy

A 
alkalosis
hypokalemia
sedating drugs - narcotics, sleep pills
GI bleeding
systemic infection
hypovolemia
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68
Q

CF of hepatic encephalopathy

A

changes in mental function
asterixis
rigidity/hyperreflexia
fetor hepaticus - musty odor of breath

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69
Q

Tx. of hepatic encephalopathy

A

lactulose

neomycin - kills GI flora that produces ammonia

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70
Q

hepatorenal syndrome

A

progressive renal failure secondary to renal hypoperfusion resulting from vasoconstriction of renal vessels (afferent arteriole) in the setting of advanced liver disease

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71
Q

CF of hepatorenal syndrome

A 
azotemia
oliguria
hyponatremia
hypotension
low U-Na+ (<10)
no improvement after 1.5 L saline = diagnostic
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72
Q

diagnosis of hepatoregnal syndrome

A

decreased GFR In absence of shock, proteinuria or other clear cause of renal failure and a failure to respond to 1.5L normal saline bolus

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73
Q

Tx. hepatorenal syndrome

A

liver transplantation

medical - midodrine, octreotide

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74
Q

a patient with ascites develops fever, vomiting, rebound abdominal tenderness and changes in mental status - what should you consider?

A

spontaneous bacterial peritonitis

- MC agent is E.coli

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75
Q

how do you confirm diagnosis of spontaneous bacterial peritonitis?

A

paracentesis - WBC > 500, PMNs > 250

- do gram stain and culture before picking antibiotic (usually 3rd gen cephalosporin)

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76
Q

how do you monitor progress in spontaneous bacterial peritonitis?

A

repeat paracentesis in 2-3 days to document a decrease in ascitic fluid PMNS < 250

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77
Q

how do you tx. coagulopathy associated with cirrhosis?

A

fresh frozen plasma

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78
Q

how do you diagnose Wilson’s disease?

A

increased LFTs
increased PT/PTT - coagulopathy
decreased serum ceruloplasmin levels
biopsy - increased copper concentration

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79
Q

young patient presents with liver disease and neurological signs, including parkinsonian symptoms and psychosis/personality changes - what should you consider?

A

Wilson’s disease - copper commonly accumulates in liver and brain
- if dx, should screen first degree relatives as well

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80
Q

Tx. of Wilson’s disease

A

symptomatic pts - D-penicillamine (chelator)

asymptomatic/pregnant pts - Zinc (prevents uptake of dietary copper)

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81
Q

what can cause secondary hemochromatosis?

A

multiple blood transfusions

chronic hemolytic anemias

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82
Q

complications of hemochromatosis

A 
cirrhosis
cardiomyopathy
diabetes mellitus
arthritis - 2/3 MCP, hips and knees
hypogonadism
hypothyroidism
hyperpigmentation of the skin
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83
Q

what should you order if a pt presents with mild elevations of ALT and AST levels?

A

iron studies - if elevated, obtain a liver biopsy to dx. hemachromatosis

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84
Q

lab findings in hemochromatosis

A

elevated serum iron, ferritin and transferrin saturation; decreased TIBC
- liver biopsy is diagnostic w/ elevated iron stores

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85
Q

Tx. of choice for hemochromatosis

A

repeated phlebotomies

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86
Q

how do you diagnose hepatic adenoma?

A

CT scan, USG or hepatic arteriography (most accurate, but invasive)

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87
Q

how do you tx. hepatic adenoma?

A

stop OCPs - if may regress

surgical resection of tumors > 5cm

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88
Q

how can you diagnose a cavernous hemangioma?

A

USG or CT scan w/ contrast

- biopsy is c/i due to risk of hemorrhage

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89
Q

Tx. of cavernous hemangioma

A

most do not require tx; consider resection if pt is symptomatic or there is high risk of rupture

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90
Q

what type of liver tumor is similar to hepatic adenoma on imaging but has no malignant potential and is not assoc. with OCP use?

A

focal nodular hyperplasia

- usually asx and no tx. needed

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91
Q

what type of liver cancer is associated with hepB/C and cirrhosis, is generally unresectable w/ a short survival time?

A

non-fibrolamellar (most common)

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92
Q

what type of hepatocellular ca. is resectable with longer survival time, usually seen in young adults?

A

fibrolamellar type

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93
Q

what should you consider in a patient with liver cirrhosis, a palpable mass and elevated AFP?

A

hepatocellular carcinoma

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94
Q

what is needed for the definitive diagnosis of hepatocellular ca?

A

liver biopsy

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95
Q

what tumor marker is elevated in HCC?

A

AFP

- useful as screening tool and for monitoring response to therapy

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96
Q

paraneoplastic syndromes caused by HCC?

A 
erythrocytosis
thrombocytosis
hypercalcemia
carcinoid syndrome
hypertrophic pulmonary osteodystrophy
hypoglycemia
high cholesterol
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97
Q

Tx. of hepatocellular carcinoma

A

liver resection or liver transplant

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98
Q

your obese, diabetic patient comes in for routine blood work and results show mildly elevated liver enzymes - dx? tx?

A

most likely non-alcoholic steatohepatitis

tx. is unclear

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99
Q

a young male comes in because he noticed he turned yellow after fasting for the past 3 days; you do blood work and find isolated elevated UCB - dx?

A

Gilbert’s disease

- decreased activity of hepatin uridine diphosphate glucoronyl transferase

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100
Q

a patient comes in with melena, hematemesis, jaundice and RUQ pain; upper GI endoscopy shows blood draining out of ampulla of Vater

A

hemobilia

- blood draining into duodenum via CBD

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101
Q

what is the diagnostic test for hemobilia

A

arteriogram

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102
Q

consequences of liver cysts associated with polycystic kidney disease?

A

rarely lead to hepatic fibrosis or failure; usually asymptomatic and dont usually need treatment

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103
Q

a patient presents with a diagnosed large cyst on right lobe of liver; he currently has RUQ pain - what are you worried about? how would you treat this?

A
  • hydatid liver cyst caused by Echinococcus; dont want it to rupture bc can result in anaphylactic shock
  • tx. is surgical resection and mebendazole
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104
Q

MC location for liver abscesses

A

right liver lobe

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105
Q

how do you diagnose a liver abscess?

A

ultrasound or CT scan

usually also have elevated LFTs

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106
Q

how do you tx. a liver abscess?

A

IV antibiotics

percutaneous drainage of abcess (sometimes surgical drainage is necessary)

107
Q

a homosexual man presents with fever, RUQ pain, NV, hepatomegaly and bloody diarrhea - what should you consider?

A

amebic liver abscess (entameoba histolytica)

108
Q

how can you diagnose amebic liver abscess?

A

serology - IgG enzyme immunoassay

109
Q

Tx. of amebic liver abscess?

A

IV metronidazole

- may require therapeutic aspiration if large or not going away with medical therapy

110
Q

occlusion of hepatic venous outflow leading to hepatic congestion and microvascular ischemia

A

Budd Chiari syndrome

111
Q

causes of Budd Chiari syndrome

A 
hypercoagulable states
myeloproliferative disorders
pregnancy
chronic inflammatory diseases
infection
various cancers/trauma
112
Q

how do you diagnose Budd Chiari syndrome?

A

hepatic venography

serum ascites albumin gradient > 1.1 g/dL

113
Q

how do you tx. Budd Chiari syndrome?

A

balloon angioplasty with stent in IVC

portocaval shunts

114
Q

at what level of bilirubin does jaundice become evident?

A

total bilirubin > 2 mg/dL

115
Q

which form of bilirubin is tightly bound to albumin (water insoluble) and cannot be excreted in urine; also if unbound from albumin, can cross BBB and become toxic?

A

unconjugated bilirubin - indirect

116
Q

dark urine and pale stools mean…

A

conjugated bilirubinemia

117
Q

a patient comes in with jaundice, lighter stools and dark urine; he also complains of pruritus - lab tests reveal elevated ALP and serum cholesterol; you notice he has skin xanthomas - what should you consider?

A

cholestasis - blockage of bile flow with resultant increase in CB levels
- he is at risk for malabsorption of fat and fat soluble vitamins

118
Q

in what scenarios are AST and ALT mildly elevated (hundreds)?

A

alcoholic hepatitis

chronic viral hepatitis

119
Q

in what scenarios are AST and ALT moderately elevated (high hundred to thousands)

A

acute viral hepatitis

120
Q

in what scenarios are ALT and AST extremely elevated (> 10 000)?

A

ischemia, shock liver
acetaminophen toxicity
severe viral hepatitis

121
Q

if you find an elevated ALP in a patient, what is the next test you should order?

A

GGT - to see if ALP is hepatic in origin (GGT will also be elevated)

122
Q

cholestatic LFTs

A

ALP and GGT

- if these are positive, obtain abdominal or RUQ ultrasound

123
Q

biliary colic

A

cardinal sx of gallstones; temporary obstruction of cystic duct by gallstone

124
Q

boa’s sign

A

referred subscapular pain of biliary colic

125
Q

test of choice to dx. cholelithiasis (gallstones)

A

RUQ ultrasound

126
Q

Tx. of gallstones

A

asymptomatic - do nothing

symptomatic - laparascopic cholecystectomy

127
Q

what do you do if a pt refuses laparascopic cholecystectomy?

A

rx. ursodeoxycholic acid - but this is expensive and has a high risk of recurrence; used in pts who are not good surgical candidates

128
Q

signs of acute cholecystitis

A

RUQ pain
Murphy’s sign - pathognomic
hypoactive bowel sounds
low grade fever/leukocytosis

129
Q

USG findings show thickened gallbladder wall, pericholecystic fluid, distended gallbladder and presence of stones - what is the dx?

A

acute cholecystitis

130
Q

what study do you perform to assess complications of acute cholecystitis?

A

CT scan

131
Q

what test do you do if the USG findings in suspected acute cholecystitis are inconclusive?

A

HIDA scan - gallbladder is not visualized 4 hours after injection

132
Q

Tx. for acute cholecystitis

A

admit to hospital - supportive measures include IV fluids, antibiotics, analgesics, NPO

133
Q

what is the most appropriate next step once a patient is recovered from acute cholecystitis (or stable)

A

laparascopic cholecystecomy - best w/in 24-48 hours

134
Q

Tx of choice for acalculous cholecystitis?

A

emergent cholecystectomy

- if pt is to ill for surgery, do percutaneous drainage with cholecystomy

135
Q

pt presents with RUQ/epigastric pain and jaundice; labs show elevated total and direct bilirubin and ALP - dx? and test? and tx?

A

choledolithiasis

  • do USG first followed by ERCP (gold standard)
  • tx. ERCP stone removal and sphincterectomy and stent
136
Q

pt presents with RUQ pain, jaundice and fever; soon after evaluation she develops signs of septic shock and altered mental state - what is the dx? and initial study?

A

cholangitis - medical emergency

- initial study is RUQ ultrasound (directs next step)

137
Q

how do you approach patient with cholangitis?

A

blood cultures
IV fluids
IV antibiotics - based on culture results
decompress CBD when pt is stable

138
Q

tests to do in cholangitis after RUQ ultrasound?

A

cholangiography:
PTC - if bile ducts are dilated
ERCP - if bile ducts are normal
- can only do these once patient has been afebrile for 48 hours and patient is stable; used to diagnose and decompress the CBD

139
Q

most feared complication of cholangitis?

A

hepatic abscess

140
Q

what do you do with a finding of porcelain gallbladder?

A

prophylactic cholecystectomy

- 50% will develop cancer

141
Q

pt presents to you with jaundice and pruritus of the skin; she also feels more tired lately and has been losing weight; she is scared this is related to her ulcerative colitis - what are you thinking of?

A

primary sclerosing cholangitis

- do ERCP and PTC to diagnose

142
Q

biopsy findings in ERCP and PTC

A

multiple bead-like strictures and dilations of both intra and extrahepatic bile ducts

143
Q

tx. of primary sclerosing cholangitis

A

liver transplant

ERCP w/ stenting to relieve symptoms of strictures; cholestryamine to help with pruritus

144
Q

pt with UC comes in complaining of severe pruritus at night; she has some RUQ discomfort and fatigue, you do tests and note she has high cholesterol and xanthelasmas - dx? what tests should you order?

A

consider primary biliary cirrhosis

order antimitochondrial ab’s and liver biopsy to confirm diagnosis

145
Q

lab findings in primary biliary cirrhosis

A

cholestatic LFTs
positive AMAs
elevated cholesterol, HDL
elevated IgM

146
Q

what drug has been shown to slow progression of primary biliary cirrhosis?

A

ursodeoxycholic acid

- but liver transplant is only curative tx

147
Q

Klatskin tumor

A

cholangiocarcinoma - in proximal 1/3 of CBD involving junction of right and left ducts; MC but worst prognosis bc it is unresectable

148
Q

RFs for cholangiocarcinoma

A

primary sclerosing cholangitis
UC
choledochal cysts
clonorchis sinensis (Hong Kong)

149
Q

a woman presents with epigastric pain, jaundice and fever; a RUQ mass is felt on physical exam - what tests should you order? what is your suspected diagnosis?

A

dx - choledochal cyst

tests - USG first, ERCP is definitive test

150
Q

choledochal cyst

A

cystic dilation of biliary tree in either extrahepatic or intrahepatic ducts

151
Q

Tx. of choledochal cysts

A

surgery - complete resection of cyst with biliary-enteric anastomosis to restore continuity of biliary system with bowels

152
Q

pt comes in with her 5th episode of biliary colic, you do another USG and again find no gallstones - what study should you consider next? diagnosis?

A

possible biliary dyskinesia (motor dysfunction of sphincter of oddi)
- order HIDA scan (w/ CCK IV to determine ejection fraction of gallbladder

153
Q

tx. of biliary dyskinesia

A

laparscopic cholecystectomy or endoscopic sphincterectomy

154
Q

Rovsing’s sign

A

appendicitis

- deep palpation in LLQ causes pain in RLQ

155
Q

Psoas sign

A

appendicitis

- RLQ pain when right thigh is extended as patient lies on left side

156
Q

obturator sign

A

appendicitis

- RLQ pain when flexed right thigh is internally rotated when patient is supine

157
Q

dx. of appendicitis

A

clinical diagnosis!!

- can do a CT scan or USG if uncertain or atypical presentation

158
Q

what nutritional deficiency is someone with a carcinoid tumor at risk for?

A

niacin deficiency - pellagra

- use up all tryptophan to make serotonin

159
Q

tx. of carcinoid tumor

A

surgery

- if unable to resect: octreotide

160
Q

drugs that can cause pancreatitis

A

diuretics - thiazides, loops
IBD - sulfasalazine, 5ASA
immunosuppressants - azathioprine, asparaginase
epileptic drugs - valproate
AIDs - didanosine, pentamidine
antibiotics - metronidazole, tetracycline

161
Q

main RFs for pancreatitis

A

alcohol
gallstones
post-ERCP - 10% of pts
blunt abdominal trauma - children

162
Q

classic pain seen in acute pancreatitis

A

epigastric pain that radiates to the back; worse when supine and after meals

163
Q

Ranson’s admission criteria for acute pancreatitis

A

GA-LAW

  • glucose > 200 mg/dL
  • age > 55 yo
  • LDH > 350
  • AST > 250
  • WBC > 16000
164
Q

Ranson’s initial 48 hr criteria for acute pancreatitis

A

C-HOBBs

  • calcium < 8 mg/dL
  • Hct decreased by > 10%
  • PaO2 < 60
  • BUN increase > 8 mg/dl
  • base deficit > 4 mg/dL
  • fluid sequestration > 6L
165
Q

diagnostic test for acute pancreatitis

A

CT abdomen

166
Q

indications for ERCP in acute pancreatitis

A

severe gallstone pancreatitis w/ biliary obstruction OR to identify causes of recurrent pancreatitis

167
Q

how do you tell sterile from infected pancreatic necrosis?

A

CT guided percutaneous aspiration w/ gram stain and culture of aspirate
- infected needs surgical debridement and antibiotics

168
Q

diagnostic test and tx. of pancreatic pseudocyst?

A

CT scan

- treat cysts > 5 cm with drainage (percutaneously or surgically)

169
Q

complications of acute pancreatitis

A 
hemorrhagic pancreatitis
ARDS
pancreatic ascites/pleural effusion
ascending cholangitis
pancreatic abscess
170
Q

Tx, of mild pancreatitis

A

NPO - bowel rest
IV fluids
pain control - fentanyl or meperidine
NG tube if vomiting or ileus present

171
Q

tx. of severe pancreatitis

A

pts with 3+ Ranson’s criteria should be admitted to ICU

  • enteral nutrition with nasojejunal tube w/in 72 hours
  • imipenem if > 30% necrosis present
172
Q

pt comes in with chronic epigastric pain, steatorrhea and diabetes mellitus - you do XR and find calcifications - dx?

A

chronic pancreatitis

173
Q

initial study of choice for chronic pancreatitis

A

CT scan

- ERCP is gold standard but is not done routinely

174
Q

what is the stool elastase test for?

A

to diagnose malabsorption secondary to pancreatic exocrine insufficiency

175
Q

what drugs should be given with pancreatic enzyme supplements?

A

H2 blockers

- prevent degradation of enzymes in stomach acid

176
Q

surgery procedure most commonly done for relief of incapacitating pain due to chronic pancreatitis?

A

pancreaticojejunostomy

177
Q

pancreatic cancer of head - symptoms?

A

weight loss
steatorrhea
obstructive jaundice

178
Q

pancreatic cancer of body/tail - symptoms?

A

pain

weight loss

179
Q

CF of pancreatic cancer

A 
abdominal pain - vague, dull ache
jaundice - increased CB and ALP
weight loss/anorexia
recent glucose intolerance
migratory thrombophlebitis
palpable gallbladder
180
Q

preferred test for assessment and diagnosis of pancreatic cancer

A

CT scan

181
Q

most sensitive test for dx. pancreatic cancer

A

ERCP

182
Q

patient presents with small upper GI bleed from duodenum; in his history he has previously had aortic graft surgery - what should you do?

A

perform endoscopy or surgery immediately - you are afraid of lethal aortoenteric fistula

183
Q

Diuelafoy’s vascular malformation

A

submucosal dilated arterial lesions that can cause massive upper GI bleeding

184
Q

other than blood, what can cause dark stools?

A 
charcoal
bismuth
iron
spinach
licorice
185
Q

initial test in hematemesis

A

upper GI endoscopy

186
Q

initial test in hematochezia

A

rule of anorectal cause

order colonoscopy

187
Q

initial test in melena

A

upper GI endoscopy

- if nothing found, order colonscopy

188
Q

initial test in occult blood

A

colonoscopy

189
Q

elevated PT may be indicative of.. (4)

A

liver dysfunction
vit K deficiency
consumption coagulopathy
warfarin therapy

190
Q

what lab finding may be elevated in Upper GI bleeding?

A

BUN-Cr ratio - the higher the ratio, the more likely the bleeding is from an upper GI source

191
Q

most accurate test for Upper GI bleeding

A

upper endoscopy

192
Q

what is top priority in pt with GI bleed?

A

fluid resuscitation if hemodynamically unstable

193
Q

what is usually the initial procedure in GI bleed?

A

nasogastric tube - empties stomach, prevents aspiration and assesses fluid

194
Q

what is the general rule for replacement fluids in pt who has lost a lot of blood due to GI bleed?

A

3 ml crystalloid fluids for every 1 ml of blood lost

195
Q

what test definitively locates the point of bleeding - usually used in lower GI bleeds?

A

arteriography

- should be performed during active bleeding and may be potentially therapeutic

196
Q

Tx. for upper GI bleeding

A

EGD with coagulation of bleeding vessel

- repeat endoscopic therapy or surgical intervention if the bleeding continues

197
Q

indications for surgery in GI bleeding (5)

A
  1. hemodynamically unstable patients despite all interventions
  2. severe initial bleed or recurrence
  3. longer than 24 hours
  4. visible vessel at base of ulcer
  5. ongoing transfusion - 5 units w/in 4-6 hrs
198
Q

main RFs for squamous cc. of esophagus

A 
alcohol
tobacco use
diet, HPV, achalasia, Plummer-VInson
caustic injury
nasopharyngeal carcinoma
199
Q

main RFs for adenocarcinoma of esophagus

A

GERD and Barret’s esophagus

200
Q

what test can confirm diagnosis of esophageal ca?

A

upper endoscopy with biopsy and brush cytology

- if negative, do a CT scan

201
Q

what test is usually the first to be done if a patient presents with dysphagia?

A

barium swallow

202
Q

what test is done to stage esophageal cancer?

A

transesophageal ultrasound

203
Q

Tx of esophageal cancer

A

surgery for stages 0,1,2a - localized to esophagus; chemo + radiation before surgery may prolong survival

204
Q

incomplete relaxation of LES and aperistalsis of esophagus are seen in?

A

achalasia

205
Q

type of dysphagia common in achalasia

A

dysphagia for both solids and liquids (vs. esophageal ca. it is initially for solids, then liquids)

206
Q

clinical features characteristic of achalasia

A

dysphagia - drink lots of water while eating, move around, twist etc. to push it down
regurgitation of food
complications of aspiration

207
Q

confirmatory test for achalasia

A

manometry

- shows failure of LES relaxation (increased pressure) and aperistalsis of esophageal body

208
Q

what should patients with achalasia be monitored for and how?

A

squamous cell ca. of esophagus

- do surveillance esophagoscopy to detect tumor at early stage

209
Q

initial Tx. for achalasia

A

medical

  • try antimuscarinic agenst, sublingual nitro, long acting nitrates or CCBs
  • improve swallowing in early stages
210
Q

definitive “palliative” tx. for achalasia

A

pneumatic dilation

- botox injections may be effective but need to be repeated every 2 years

211
Q

in pts who do not respond to dilation therapy for achalasia, what can you do?

A

surgery - heller myotomy

212
Q

patient presents with chest pain mimicking angina that radiates to the jaw; he also complains of dysphagia - diagnosis and test?

A

possibly diffuse esophageal spasm

  • should R/O cardiac causes of pain
  • upper GI barium swallow
213
Q

manometry findings in diffuse esophageal spasm?

A

diagnostic - simultaneous, multiphasic, high amplitude, repetitive contractions; normal relaxation of LES

214
Q

Tx. of diffuse esophageal spasm

A

antispasmolytics - nitrates and CCBs

TCAs - may provide sx relief

215
Q

which type of esophageal hiatal hernias are benign and associated with GERD?

A

sliding hernia

216
Q

which type of esophageal hernias can become strangulated, enlarge over time so that whole stomach is in thorax and need to be tx. surgically?

A

paraesophageal hiatal hernia

217
Q

complications of sliding hiatal hernias

A

GERD
aspiration
esophagitis

218
Q

complications of paraesophageal hernias

A

strangulation
obstruction
hemorrhage

219
Q

Tx. of sliding hiatal hernia

A

medical - anatacids, small meals, elevation of head when sleeping
surgery - Nissen’s fundoplication

220
Q

Tx. of paraesophageal hernia

A

elective surgery to prevent complications

221
Q

alcoholic pt presents with hematemesis; last night he binge drank and has been vomiting ever since - likely dx?

A

Mallory-Weiss syndrome

- ruptured submucosal aa of distal esophagus and proximal stomach

222
Q

first step in Mallory-Weiss syndrome?

A

upper endoscopy - diagnostic

223
Q

Tx. of Mallory-Weiss syndrome

A

90% heal on their own
can try vasopressin, endocscopic injection or electrocautery
if still continues, surgery (oversew the tear) or angiographic embolization

224
Q

pt presents with dysphagia, glossitis and iron deficiency anemia?

A

Plummer-Vinson syndrome - upper esophageal webs

225
Q

what are patients with Plummer-Vinson syndrome at risk for?

A

SCC of oral cavity, hypopharynx and esophagus

226
Q

Tx. of Plummer-Vinson syndrome

A

esophageal dilation

227
Q

what does ingesting alkali do to you esophagus?

A

liquefactive necrosis with full thickness necrosis; may be complicated with stricture formation and esophageal cancer

228
Q

tx. of necrosis from alklai ingestion

A

esophagectomy

  • avoid vomiting, oral intake and gastric lavage
  • steroids and antibiotics
  • bougienage for strictures
229
Q

pt presents with dysphagia, regurgitation, bad breath and chronic cough - what can you suspect?

A

Esophageal diverticulum

230
Q

pt presents with oropharyngeal dysphagia and a neck mass that varies in size depending on fluid/food intake

A

Zenker’s diverticulum

- MC type; in upper third of esophagus

231
Q

cause of Zenkers

A

failure of cricopharyngeal mm to relax during swallowing leading to increased intraluminal pressure and outpouching of mucosa through weakened muscle

232
Q

traction diverticula

A

midpoint of esophagus; caused by contiguous mediastinal inflammation and adenopathy that causes retraction of esophagus; no tx. required

233
Q

epiphrenic diverticula

A

lower third of esophagus due to spastic esophageal dysmotility or achalasia

234
Q

diagnostic test for diverticula in esophagus

A

barium swallow

235
Q

intermittent dysphagia for solids only

A

lower esophageal ring

236
Q

progressive dysphagia for solids only

A

can be either peptic stricture or cancer

237
Q

intermittent dysphagia for solids and liquids with chest pain

A

diffuse esophageal spasm

238
Q

Hamman’s sign

A

mediastinal crunch - heart beating against air filled tissues in esophageal rupture

239
Q

diagnostic study for ruptured esophagus

A

contrast esophagram with soluble Gastrograffin swallow

240
Q

tx for esophageal rupture

A

surgery within 24 hours greatly improves survival

241
Q

most accurate/preferred test for diagnosing ulcers

A

endoscopy

242
Q

gold standard for dx. H.pylori

A

endoscopic biopsy

243
Q

when is the urea-breath test ok to you for dx of h.pylori?

A

documents active infection

assesses results of antibiotic therapy

244
Q

what are the three tests that can test for h.pylori?

A

biopsy
urea-breath test - most convenient
serology - ab’s can remain elevated longer after eradication

245
Q

triple therapy for h.pylori

A

PPI, amoxicillin and clarithromycin

- 10 days to 2 weeks

246
Q

what drug can be used to reduce risk for ulcer formation associated with NSAID therapy

A

misoprostol

247
Q

what kind of therapy is pretty much essential in pts with duodenal ulcers?

A

triple therapy for h.pylori

248
Q

how long should a pt with PUD take anti-secretory drugs for?

A

4-6 weeks if uncomplicated ulcers and patient is asymptomatic; if pt is at risk for recurrence, consider maintenance therapy

249
Q

how do you diagnose gastric outlet obstruction?

A

saline load test - empty stomach with NG tube, infuse 750 ml of saline, wait 30 min and aspirate; positive if > 400 ml aspirated

250
Q

MCC of gastric outlet obstruction

A 
duodenal ulcers
type III (prepyloric) gastric ulcers
251
Q

how do you diagnose perforation of ulcer?

A

upright CXR shows free air under diaphragm

CT scan is the most sensitive test for perforation

252
Q

best test for evaluating pt with epigastric pain

A

upper endoscopy

253
Q

pt presents with severe hemorrhagic gastric lesions after exposure of gastric mucosa to injurious agents such as NSAIDS and alcohol

A

acute erosive gastritis

254
Q

what test is used to dx gastric cancer and what test is used for staging?

A

dx - endoscopy w/ multiple biopsies

stage - CT scan

255
Q

5 sites of mets from gastric cancer

A 
Krukenberg - ovary
Virchow's node - supraclavicular
Irish's node - left axillary node
Blumer's shelf - pelvic cul de sac (rectum)
Sister Mary Joseph - periumbilical node
256
Q

how can you clinically tell apart a proximal vs. distal small bowel obstruction?

A

proximal has lots of vomiting and severe pain whereas distal obstruction has significant abdominal distention

257
Q

acid-base disorder in small bowel obstruction

A

hypochloremic, hypokalemia, metabolic alkalosis

258
Q

what are the indications for surgery in bowel obstruction?

A

complete obstruction
partial obstruction that is persistent or assoc. with constant pain
strangulation if suspected

259
Q

abdominal films show a uniform distribution of gas in the small bowel, colon and rectum

A

paralytic ileus

260
Q

failure to pass contrast medium beyond a fixed point

A

paralytic ileus

261
Q

Tx of paralytic ileus

A

usually resolves with time or when the cause is addressed medically
- surgery is not usually needed

262
Q

Tx. algorithm for Crohn’s disease

A
  1. 5-ASA - esp. useful if colon involved
  2. metronidazole - if 5ASA doesnt work
  3. steroids - acute exacerbations/ if metro doesnt work
  4. immunosuppressants (azathioprine) - with steroids
  5. surgery - for complications
263
Q

Drugs that cause esophagitis

A

Antibiotics: Tetracyclines
Anti-inflammatory : Aspirin and NSAIDs
Bisphosphonates: Alendronate
Other: KCl, quinidine, Iron

Internal Medicine (9 decks)

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