GI 10% Flashcards
HCl in the stomach is secreted by __ cells
Pepsin secreted by __ cells
- Hcl - parietal cells
- Pepsin - chief cells
- ->HCl activates pepsinogen to pepsin
Medications that should be avoided in GERD b/c they lower esophageal sphincter pressure
Beta agonists alpha-adrenergic antagonists Nitrates CCB Anticholinergics Theophylline Morphine Meperidine Diazepam Barbiturates
Tx of CMV esophagitis
IV ganciclovir
T/F - Somatostatin stimulates the release of GI hormones
FALSE - suppresses
ex. suppress gastrin secretion from G cells in stomach
ex. suppress CCK, VIP, insulin, pancreatic enzymes
T/F - Lower GI series (aka barium enema) is the test of choice in acute ulcerative colitis
FALSE - contraindicated because may cause toxic megacolon
-also CI if perforation is suspected
MC cause of esophagitis
GERD (duh)
esophageal findings on endoscopy - what dx?
- large superficial shallow ulcers
- small, deep ulcers
- linear yellow-white plaques
- large superficial shallow ulcers = CMV
- small, deep ulcers = HSV
- linear yellow-white plaques = Candida
All are infectious esophagitis, MC in immunocompromised pts
treatment of candida infectious esophagitis
oral fluconazole
Tx of HSV esophagitis
Acyclovir
medication classic for causing pill esophagitis
Bisphosphonates
others = NSAIDS, KCl, iron pills, BBs, CCBs
Multiple corrugated rings on endoscopy seen in ___
Eosinophilic esophagitis
gold standard to diagnose GERD
24 hr ambulatory pH monitoring
- not usually done
- 1st line = endoscopy
- 2nd line = esophageal manometry
what should be done if GERD is presenting with alarm symptoms (dysphagia, odynophagia, wt loss, bleeding)
don’t just treat! Upper Endoscopy
loss of Auerbach’s plexus leading to increased LES pressure
Difficulty with ___
Dx gold standard:
Tx:
Achalasia
Both liquid and solids
Esophageal manometry
Botox injections (temporary relief)
Nitrates, CCB, pneumatic dilation of LES
Esophagomyomectomy
Neurogenic dysphagia causes difficulty with ___.
Caused by injury/disease of brain stem for CN ___.
Both liquid and solids
CN 9, 10
“corkscrew esophagus” seen on esophagram
diffuse esophageal spasm
-chest pain w/ hot or cold liquids, foods
MC types Esophageal neoplasms in: African Americans: Smoking/ETOH: GERD/Barrett's esophagus: Obesity:
African Americans: Squamous cell
Smoking/ETOH: Squamous cell
GERD/Barrett’s esophagus: Adenocarcinoma
Obesity: Adenocarcinoma
Squamous cell esophageal cancer MC in ___
Adenocarcinoma of esophagus MC in ___
SC: upper 1/3 of esophagus
AD: lower 1/3
Dx of esophageal neoplasm
Best initial:
Test of choice:
Staging:
Best initial: Biphasic barium esophagram
Test of choice: Endoscopy w/ bx
Staging: Endoscopic sonography, CT
pharyngoesophageal pouch is aka ___
Zenker’s diverticulum – dx via barium esophogram
T/F - Mallory Weiss tear can present with pneumomediastinum
FALSE - this is Boerhaave’s syndrome - FULL thickness rupture of distal esophagus
Crepitus on chest auscultation
Plummer-Vinson Syndrome consists of (3)
- dysphagia
- esophageal webs
- Fe def anemia
* atrophic glossitis
- -this is a congenital syndrome
Dx test of choice for esophageal webs
barium esophagram
abx prophylaxis in esophageal variceal bleed to prevent infectious complications
FQs (ex. Norfloxacin)
or
Ceftriaxone
treatment of choice in acutely bleeding esophageal varices
endoscopic ligation (**after IV fluids via 2 lg bore IVs and stabilization of the pt of course)
pharmacologic drug of choice in acutely bleeding esophageal varices
octreotide
__% of esophageal variceal bleeds that RE-BLEED within 1 year
–preventative treatment?
70%!! (1/3 of re-bleeds are fatal)
TX = BB’s (nonselective - ex. propranolol, nadolol)
NOT used in acute bleeds
Budd-Chiari syndrome may cause ____
thrombosis of portal vein, leading to esophageal varices
MC type of hiatal hernia
Type 1 = sliding hernia
TX = same as GERD
How often and with what diagnostic tool should people with Barrett’s esophagus be screened for cancer?
Every 3-5 years with Endoscopy
MC cause of gastritis
H pylori
Gold standard to dx gastritis
Endoscopy (shows thick, edematous erosions <0.5cm)
H pylori treatment
“CAP”
Clarythromycin + amoxicillin + PPI
(If allergic to penicillin –> Metronidazole)
T/F - Gastric ulcers are 4x more common than duodenal ulcers
–Duodenal or gastric seen in younger population?
FALSE! - Duodenal 4x more common than gastric
–Duodenal seen in younger population (30-55yo)
Tx of delayed gastric emptying
Prokinetic medications:
Cisapride, metoclopramide
(Duodenal/gastric) ulcers worsen with food, whereas (duodenal/gastric) ulcers improve with food.
GASTRIC ulcers WORSEN with food, whereas DUODENAL ulcers IMPROVE with food.
Tests that can confirm cure of H. pylori PUD
Stool antigen testing
Urea breath test
Accurate after 4 weeks AFTER completion of treatment
Gold standard to dx H pylori infection
Endoscopy (with biopsy! to rule out malignancy especially with gastric ulcers if alarm sx)
–positive urease test of biopsy specimen
Which of the following should NOT be used to confirm eradication of H pylori infection
A. urea breath test
B. H pylori stool antigen
C. serologic antibodies
C - serologic antibodies only used to confirm infection, can stay elevated long after eradication
- the other 2 can be used for dx and eradication
- -make sure urea breath test, pt is OFF PPIs
(duodenal or gastric) ulcers are typically better with meals, worse at night
duodenal
-gastric ulcers are worse esp 1-2h post meals
H2 receptor antagonist with lots of drug interactions
cimetidine
-b/c inhibitors CYP450 (remember C for CYP inhibitor)
Side effect of H2 receptor antagonists (general)
Side effect of cimetidine specifically
Inc LFTs
– Cimetidine –> anti androgen (gynecomastia, impotence)
Side effect of PPIs
B12 deficiency
Prostaglandin E1 analog useful for preventing NSAID induced gastric ulcers
Misoprostol
Dx to suspect if: multiple peptic ulcers, “kissing ulcers”, refractory ulcers to tx
Zollinger Ellison Syndrome
gastrinoma
best screening test for Zollinger Ellison Syndrome
fasting gastrin levels
Secretin test used to help diagnose ___
Zollinger Ellison Syndrome
secretin normally inhibits gastrin secretion. With this test, increased gastrin levels (>200 pg/mL) regardless of secretin administration
Linitis plastica
diffuse thickening of stomach wall due to gastric cancer infiltration
Krukenberg tumor
a malignancy in the ovary that metastasized from a primary site, classically the GI Tract (gastric adenocarcinoma MC)
MC type of gastric carcinoma
adenocarcinoma
“string sign” seen on upper GI contrast study
pyloric stenosis
NOTE: String sign can also be seen in barium studies in Crohn’s
Budd Chiari Syndrome
- what is it?
- classic triad of sx?
Hepatic vein obstruction
SX = 1. ascites 2. hepatomegaly 3. RUQ abd pain
MC cause of gastroenteritis in US in adults? In kids?
Adults - norovirus
Kids - rotavirus
All of the following are causes of NON-invasive infectious diarrhea EXCEPT: A. Staphylococcus B. Vibrio C. C. diff D. Shigella E. Enterotoxigenic E. Coli
D - Shigella causes invasive infectious diarrhea
Note: enterohemorrhagic E coli is a cause of invasive, NOT Enterotoxigenic
rice water stools leading to severe dehydration
Tx:
Vibrio cholerae (non invasive diarrhea) *Mainstay of tx = fluid replacement
MC cause traveler’s diarrhea
TX?
Enterotoxigenic E coli
TX = FQ (ex. cipro)
Abx notorious for causing C. diff
Clindamycin
diarrhea w/ very high lymphocytosis and pseudomembranous coliti
C. diff
TX of C diff (1st and 2nd line)
1st line = metronidazole
2nd line = vancomycin
key differentiating factor between invasive and noninvasive diarrhea
+ blood and fecal leukocytes w/ fever in invasive
—non invasive will have voluminous watery stools, vomiting
Tx of choice of Shigella
TMP-sulfa (Bactrim)
pea soup stools
Salmonella
diarrhea a kid gets after playing w/ pet turtle
Salmonella
treatment of typhoid fever/ salmonella gastroenteritis
FQs or ceftriaxone x 2 wks
pt w/ HA, pharyngitis –> progresses to diarrhea, intractable fever, bradycardia –> rose spots in 2nd week
Thyphoid (enteric) fever caused by Salmonella
MC cause of bacterial enteritis in US
Campylobacter (blood diarrhea)
“S or seagull shaped” organisms seen on stool culture
Campylobacter (GN bacteria) - also described as “comma shaped”
Tx of Campylobacter diarrhea
Erythromycin
FQs if severe
frothy, greasy diarrhea after camping
TX?
Giardia (protozoal infection)
TX = metronidazole
MC cause of chronic diarrhea in AIDS pts
Cryptosporidium
no proven treatments
PAS-positive macrophages on duodenal bx seen in __
Whipple’s ds
(osmotic / secretory) diarrhea will have a HIGH osmotic gap, dec diarrhea with fasting
Osmotic
2 stimulant laxatives that inc Ach GI motility
Bisacodyl
Senna
examples of osmotic laxatives (4)
- polyethylene glycol (Miralax)
- Lactulose
- sorbitol
- Milk of Mg or Mg Citrate
Peginterfera alpha for Hep C contraindicated if (4)
- autoimmune ds,
- pregnant,
- decompensated cirrhosis,
- profound cytopenias
salmon colored esophageal mucosa
Barrett’s esophagus
2 measurements of liver function
- albumin
- coagulation factors (prolonged PT)
(ALT/ AST are not function tests!)
MC cause of appendix obstruction? 2nd MC cause?
- lymphoid hyperplasia
2 fecalith
what type of hernia might present with Howship-Romberg sign (aresthesias along medial thigh)
obturator
-d/t compression of obturator nerve
triad of 1. vomiting 2. abd pain 3. currant jelly stools
intussusception
___ sign = sausage shaped mass in RUQ. Associated with ___
Dance’s sign
-intussusception
D-xylose test
Distinguishes maldigestion (pancreatic insufficiency, bile salt deficiency) from malabsorption
Hydrogen breath test
Test of choice in dx of Lactose Intolerance
2 Abs positive in celiac ds
- Endomysial IgA Ab
2. transglutaminase Ab
skin disorder associated with celiac ds
dermatitis herpetiformis (pruritic, papulovesicular rash on extensor surfaces)
“skip lesions” with cobblestone appearance
Crohn’s
stovepipe sign
ulcerative colitis (loss of haustral markings)
(UC or Crohn’s) - transmural invovlement
Crohn’s
-UC is mucosa and submucosa only
T/F - Barium enema is the diagnostic test of choice of UC (ulcerative colitis)
FALSE! contraindicated b/c might cause toxic megacolon
—> Flex sig is the dx test of choice
(2) 5-ASA medications used to IBD
- mesalamine (oral or topical)
- sulfasalazine - more side effects
- -used as maintenance therapy
6-mercaptopurine, azathioprine, methotrexate are steroid-sparing agents in ___
IBD
Dx of acute Crohns
Upper GI series w/ small bowel follow through
Dx of intussusception in kids? In adults?
Kids: barium or air enema
Adults: CT, abd xray
abx for diverticulitis
cipro (or Bactrim) + metronidazole x 14d
broad spectrum abx
MC cause of acute lower GI bleeding
diverticulosis
definitive diagnosis for acute mesenteric ischemia = “pain out of proportion to PE”
Angiogram
MC loss of blood to splenic flecture
chronic dull abdominal pain WORSE after meals
chronic mesenteric ischemia
d/t atherosclerosis
MC type of adenoma polyp
Type of colon polyp w/ highest risk of becoming cancerous
90% of all polyps are ___.
Tubulous adenoma
Villous adenoma
Hyperplastic ( lowest risk of malignancy)
Tubular polyps require f/u ___
Villous polyps require f/u ___
Tubular polyps require f/u Q 5 years
Villous polyps require f/u Q 3 years
mainstay of chemotherapy for colon cancer
5FU
Peutz-Jehgers
Autosomal dominant, polyposis, mucocutaneous hypergigmentation (lips, buccal, hands)
RF for colorectal cancer
R or L sided colon cancer lesion?
Chronic blood loss, iron deficiency anemia
Right
Left sided: obstructive symptoms
- indirect hernias are (lateral/medial) to the inf epigastric aa’s and pass through ____
- direct hernias are (lateral/medial) to the inf epigastric aa’s and pass through ____
- indirect - LATERAL, through internal inguinal ring
MOST COMMON - direct - MEDIAL, through external inguinal ring at Hesselbach triangle
(indirect/ direct) hernias go into the scrotum
indirect
-through persistent patent process vaginalis (MC in young children and adults)
T/F: Tx of anoreectal abscess and fistula include I&D with abx.
False. NO abx.
MC location for anal fissures
posterior midline
Anal cancer is caused by ___
HPV
MC cause of appendicitis
Fecalith
Ranson Criteria
Poor prognosis for pancreatitis
Leukocyte >16,000 Blood glucose > 200 LDH > 350 AST > 250 Arterial PO2 <60 Base deficit > 4 HYPOcalcium Increased BUN
lab values in acute pancreatitis
- (hypo/ hyper) calcemia
- (inc/ dec) triglycerides
- (hypo/ hyper) glycemia
- HYPOcalcemia
- INC TGs
- HYPERglycemia
(amylase/ lipase) more specific for acute pancreatitis
lipase
Cullen and Turner’s signs
signs of necrotizing hemorrhagic pancreatitis
- Cullins = periumbilical bruise
- Turners = flank bruise
colon cutoff sign and sentinel loop seen on abd xray
Pancreatitis
- colon cutoff = abrupt collapse of colon near pancreas
- sentinel loop = dilated small bowel loop in LUQ
Triad of chronic pancreatitis
- calcifications 2. steatorrhea 3. DM
* calcifications seen on abd Xray
70% of pancreatic adenocarcinoma are found in the (head, body, tail)?
MC type of adenocarcinoma
head
Ductal
painless jaundice = ___
pancreatic cancer
___ sign = palpable, NONtender distended gallbladder associated w/ jaundice. Associated with _____
Courvoisier’s sign
-pancreatic cancer
- MC cause of small bowel obstruction
2. MC cause of large bowel obstruction
- SBO - post surgical adhesions
2. LBO - cancer
Abd X-ray with air fluid levels in Step ladder pattern
Small bowel obstruction
Pancreatic tumor markers in pancreatic carcinoma
CEA
CA 19-9
Charcot’s triad (3)
+
Reynolds’ pentad (+2)
For Cholangitis
- Fevers/ chills
- RUQ pain
- Jaundice
- –> Reynolds - Shock (hypotension)
- Altered mental status
Boas sign
- referred pain to right sub scapular area due to phrenic nerve irritation
seen in acute cholecysitis
porcelain gallbladder seen when?
chronic cholecystitis
- cholesterol submucosal aggregation
- premalignant
Gold standard to dx cholecysitis
HIDA scan
-although RUQ US is initial test of choice
Abx used in cholecsytitis (2)
3rd gen cephalosporin + metronidazole
Abx used in cholangitis (2)
penicillin + aminoglycoside (-mycins)
T/F - morphine is the pain med of choice for acute cholecysitis
False! Ass w/ sphincter of Oddi spasm
–Meperidine (Demerol) is preferred
Treatment of cholangitis
decompression of biliary tree via ERCP stone extraction
hereditary disorder with mildly reduced UGT (glucuronosyltransferase) enzyme activity
Gilbert’s
-increased INDIRECT bilirubin w/ nml LFTs
(UGT normally conjugates indirect –> direct bill)
-no tx needed
“more severe form of Gilbert’s disease”
Crigler Najjar Syndrome - no or little UGT activity
INDIRECT bilirubin
grossly black liver and isolated mild conjugated hyperbilirubinemia
Dubin Johnson Syndrome
-hepatocytes can’t secrete conjugated bilirubin (gene mutation)
Increased DIRECT bilirubin
-no tx needed
echoic (clay colored) stools suggests ___
-would see inc (indirect/ direct) bilirubin
Biliary obstruction
- increased DIRECT (conjugated) bili
- also increased ALP and GGT
Most sensitive indicator of biliary injury
GGT
Increased ALP w/ normal GGT =
bone disease
Definitive tx of Primary sclerosing cholangitis
liver transplant
Primary sclerosing cholangitis mc associated w/ ___
Gold standard Dx:
Clinical presentation:
Ulcerative colitis
ERCP
Progressive jaundice, pruritis
Pattern of liver injury seen in alcoholic hepatitis
AST: ALT >2:1
*think S for SHOTS!
Pattern of liver injury: AST/ ALT >1,000
- acute viral hepatitis
- Usually active hep A, B, rarely C
- (ALT usually > AST)
Pattern of liver injury: ALT >1,000, + smooth mm Abs, + ANA
autoimmune hepatitis
Pattern of liver injury: inc AST/ ALT (but <400)
- chronic viral hepatitis
- Hep B, C, D
- (ALT usually > AST)
MC cause of fulminant hepatitis
acetaminophen
fulminant hepatitis in children w/ aspirin use during viral infection
- -other sx?
- -Tx?
Reye’s syndrome
- rash, vomiting, encephalopathy, dilated pupils, multi-organ failure
- TX = lower ICP w/ mannitol
only viral hepatitis associated with spiking fevers
Hepatitis A
T/F: HAV, HBV, HEV are the only ones associated w/ chronic hepatitis
False. Hepatitis B, C, D
Transmission of Hep A: Hep B: Hep C: Hep D: Hep E:
Hep A: feco-oral
Hep B: sexual, perinatal, percutaneous, perenteral
Hep C: parenteral (IVDU)»_space; sex
Hep D: parenteral, mucous membrane contact requires HBV
Hep E: feco-oral
Positive IgG HAV Ab with negative IgM HAV Ab indicates what?
Past exposure to hep A
In acute hepatitis –> IgM HAV will be positive
Diagnostic test for acute and chronic hepatitis C
HCV-RNA
(anti-HCV may be pos or neg in acute. in chronic, anti-HCV is pos)
(neg HCV-RNA = resolved infection)
treatment of chronic hep C (2)
pegylated interferon alpha-2b AND ribavirin
screening for HCC (hepatocellular carcinoma) if chronic Hep C with (2)
AFP
ultrasound
Hepatitis B serologies:
if HbsAb is present, it indicates what?
distant resolved infection OR vaccination
Hepatitis B serologies: HBsAg - neg anti-HBs Ab - neg anti-HBc Ab - *pos (IgM)* HBeAg - neg Anti-HBe Ab - neg
window period of acute infection
Hepatitis B serologies: HBsAg - *pos* anti-HBs Ab - neg anti-HBc Ab - *pos (IgM)* HBeAg - pos/neg Anti-HBe Ab - pos/neg
Acute hepatitis
Hepatitis B serologies: HBsAg - neg anti-HBs Ab - *pos* anti-HBc Ab - *pos (IgG)* HBeAg - neg Anti-HBe Ab - neg
recovery /resolved infection
- if pt hasn’t developed anti- HBs Ab in 6 months, the patient has a chronic infection
Hepatitis B serologies: HBsAg -*pos* anti-HBs Ab - neg anti-HBc Ab - *pos (IgG)* HBeAg - *pos* Anti-HBe Ab - neg
Chronic replicative hepatitis
- If HBeAg were negative and anti-HBe Ab were positive –> This indicates chronic infection (non replicative) –> waning viral replication and decreased infectivity
MELD score for end stage liver disease is calculated using (3)
- bilirubin
- INR
- creatinine
* measures 3 mo mortality
HCC is MC caused by chronic hepatitis, but can also be due to ___ exposure from ___ infection
aflatoxin exposure from Aspergillus infection
treatment for hepatic encephalopathy (2)
- lactulose (converted to lactic acid by intestinal bacteria, pulls ammonia into gut)
- neomycin (abx that decreases ammonia producing flora)
treatment for pruritus is cirrhosis
cholestryamine (bile acid sequestrant)
autosomal recessive disorder with Copper accumulation
Wilson’s disease
cholestasis disease associated with ulcerative colitis
PSC (primary sclerosing cholangitis)
Hallmark antibody for PBC (primary biliary cirrhosis)
Anti-mitochondrial Ab
1st line treatment for PBC (primary biliary cirrhosis)
ursodeoxycholic acid (reduces progression) -cure = liver transplant
Kayser Fleischer rings
corneal copper deposits seen in Wilson’s ds
inc ALP and GGT indicate __
cholestasis
-can be seen in PBC, PSC, biliary obstruction
Vit D deficiency is called ___ in kids and ___ in adults
TX = ___
Rickets in kids, osteomalacia in adults
TX = Ergocalciferol (vit D)
vitamin __ deficiency - night blindness, squamous metaplasia
Vit A
Wernicke-Korsakoff’s syndrome is caused by __ deficiency
Thiamin (B1) def
–alcoholics
3 D’s of Pellagra (aka __ deficiency)
- Diarrhea
- Dementia
- Dermatitis
aka Niacin (B3) deficiency
__ deficiency presents w/ oral-ocular-genital syndrome
Riboflavin (B2)
- Oral - magenta colored tongue, angular cheilitis
- Ocular - photophobia, corneal lesions
- Genital - scrotal dermatitis
pernicious anemia
lack of gastric parietal cells = lack of intrinsic factor —> B12 deficiency
sx of parasthesias, gait abnl, dementia, glossitis, GI problems, macrocytic anemia
B12 deficiency
PKU = reduced ability to metabolize ___ to ___
phenylalanine to tyrosine
infant presenting with vomiting, retardation, inc DTR, convulsions
PKU
mechanism of action of loperamide (Immodium) and diphenoxylate (Lomotil)
opioid agonists
-anti diarrheals
T/F - Bismuth salicylate (Pepto-Bismol) is safe in dysentery (fever, bloody diarrhea)
True
–loperamide (another anti-diarrheal) is NOT
cardiac side effect of anti emetics (ex. ondansetron, prochlorperazine)
QT prolongation
what type of hernia might present with Howship-Romberg sign (aresthesias along medial thigh)
obturator
-d/t compression of obturator nerve
Dilation of lacteals seen in ___
Caused by ____
Clinical manifestation:
Tx:
Whipple’s disease
Tropheryma whipplei: MC in farmers around contaminated soils
Malabsorption**: weight loss, fever, lymphadenopathy, arthritis, steatorrhea
Rhythmic motion of eye muscles while chewing
PCN or tetracycline for 1-2 YEARS
Roux-en-Y gastric bypass sx should be given prophylactic ____ for 6 months to reduce risk of ____.
Ursodeoxycholic acid (UDCA) gallstone
Nephrocalcinosis is common in pts with ____
Cystic fibrosis
Initial diagnostic test for C. dif
Rapid enzyme immunoassay (EIA)
LEFT supraclavicular adenopathy suggests ___
Intraabdominal cancer: kidney, ovary, testies, prostate
Celiac disease is associated with ___(2)
Down Syndrome (15%) DM1
T/F: Urethritis caused by Chlamydia will have urinalysis that shows pyuria with bacteriuria on gram stain. Ucx will show bacterial growth.
FALSE. Chlaymdia will show pyuria WITHOUT bacteriuria on gram stain. NO growth on ucx.
Men with ED should be evaluated for ____ via ____
coronary artery disease
Thallium cardiac scintigraphy
Initial diagnosis of intussusception
US of abdomen
Rice water stool from improperly cooked shellfish
Caused by ___
Cholera
Enterotoxin actively secreted by pathogen
Screening recommendation of dysplasia or adenocarcinoma in pts with Barrett esophagus
Upper endoscopy q 3-5 years
MC presentation of Crohn disease
RLQ pain
diarrhea
weight loss
Newborn screening for Cystic Fibrosis uses ___
assay for immunoreactive trypsin (IRT)
