GI

Question 1

Danger Signals

Acute A_____

Acute Ch_______

Acute D________

Acute P_______

(1) Colitis

Colon _____

C____ Disease

U______ Colitis

(1) Syndrome

Answer 1

Acute Appendicitis

Acute Cholecystitis

Acute Diverticulitis

Acute Pancreatitis

Clostridium Difficile Colitis

Colon Cancer

Crohn’s Disease

Ulcerative Colitis

Zollinger-Ellison Syndrome

Question 2

Acute Appendicitis

Patient who is a young adult complains of ____ onset of peri______ pain that is steadily getting worse. Over a period of 12 to 24 hours, the pain starts to localize at _____ point. The patient has no ______ (anorexia). Classic exam findings include low-grade ____ and right lower quadrant (RLQ) pain (McBurney’s point) with re_____ and g______. The p____ and o_____ signs are positive. When the appendix ruptures, clinical signs of acute _______ occur, such as involuntary guarding, rebound, and a b____like abdomen. Refer to ___.

Answer 2

Patient who is a young adult complains of acute onset of periumbilical pain that is steadily getting worse. Over a period of 12 to 24 hours, the pain starts to localize at McBurney’s point. The patient has no appetite (anorexia). Classic exam findings include low-grade fever and right lower quadrant (RLQ) pain (McBurney’s point) with rebound and guarding. The psoas and obturator signs are positive. When the appendix ruptures, clinical signs of acute abdomen occur, such as involuntary guarding, rebound, and a boardlike abdomen. Refer to ED.

Question 3

Acute Cholecystitis

Overw_____ gender (1) patient complains of severe (1) quadrant or epigastric pain that occurs within 1 hour (or more) after eating a _____ meal. Pain may radiate to the right ______. Accompanied by nausea/vomiting and anorexia. If left untreated, may develop ______ of the gallbladder (20%). May require hospitalization.

Answer 3

Overweight female patient complains of severe right upper quadrant (RUQ) or epigastric pain that occurs within 1 hour (or more) after eating a fatty meal. Pain may radiate to the right shoulder. Accompanied by nausea/vomiting and anorexia. If left untreated, may develop gangrene of the gallbladder (20%). May require hospitalization.

Question 4

Acute Diverticulitis

(1) Age patient with acute onset of high fever, anorexia, nausea/vomiting, and (1) quandrant abdominal pain. Risk factors for acute diverticulitis include increased a__, con_____, low dietary ____ intake, obesity, lack of exercise, and frequent (1)Rx use.

Signs of acute abdomen are rebound, positive ______ sign, and a _____like abdomen. Complete blood count (CBC) will show leuko_____ with neutro____ and shift to the _____. The presence of band forms signals severe bacterial _____ (bands are immature neutrophils). Complications include abscess, s____, il____, small-bowel _____, hemorrhage, per_____, fis____, and phlegmon stricture. May be life-threatening.

Answer 4

Elderly patient with acute onset of high fever, anorexia, nausea/vomiting, and left lower quadrant (LLQ) abdominal pain. Risk factors for acute diverticulitis include increased age, constipation, low dietary fiber intake, obesity, lack of exercise, and frequent nonsteroidal anti-inflammatory drug (NSAID) use.

Signs of acute abdomen are rebound, positive Rovsing’s sign, and a boardlike abdomen. Complete blood count (CBC) will show leukocytosis with neutrophilia and shift to the left. The presence of band forms signals severe bacterial infection (bands are immature neutrophils). Complications include abscess, sepsis, ileus, small-bowel obstruction, hemorrhage, perforation, fistula, and phlegmon stricture. May be life-threatening.

Rovsing’s sign is the finding of right lower quadrant pain during palpation of the left side of the abdomen or when left-sided rebound tenderness is elicited

Question 5

Acute Pancreatitis

Adult patient complains of acute onset of fever, nausea, and vomiting that is associated with rapid onset of abdominal pain that radiates to the _____ (“b____”) located in the _____ region.

Frequent causes include _____ (approximately 90% of cases of acute pancreatitis), biliary factors, and al____ abuse. Abdominal exam reveals guarding and tenderness over the _____ area or the upper abdomen, as well as positive ______ sign (blue discoloration around umbilicus) and (1) sign (blue discoloration on the flanks). The patient may have an ileus and show signs and symptoms of sh_____. Refer to ED

Answer 5

Adult patient complains of acute onset of fever, nausea, and vomiting that is associated with rapid onset of abdominal pain that radiates to the midback (“boring”) located in the epigastric region.

Frequent causes include drugs (approximately 90% of cases of acute pancreatitis), biliary factors, and alcohol abuse. Abdominal exam reveals guarding and tenderness over the epigastric area or the upper abdomen, as well as positive Cullen’s sign (blue discoloration around umbilicus) and Grey Turner’s sign (blue discoloration on the flanks). The patient may have an ileus and show signs and symptoms of shock. Refer to ED

Question 6

Clostridium Difficile Colitis

Severe w_____ diarrhea from __ to __ stools a day that is accompanied by lower abdominal pain with cr______ and f____. Symptoms usually appear within 5 to 10 days after initiation of _____ (such as _____ (Cleocin), fl______, ceph_____, and p______) have been implicated as the most likely cause of C. difficile infection. Most cases occur in patients in h_____ as well as those residing in n_____ facilities

Answer 6

Severe watery diarrhea from 10 to 15 stools a day that is accompanied by lower abdominal pain with cramping and fever. Symptoms usually appear within 5 to 10 days after initiation of antibiotics. (clindamycin (Cleocin), fluoroquinolones, cephalosporins, and penicillins) have been implicated as the most likely cause of C. difficile infection. Most cases occur in patients in hospitals as well as those residing in nursing facilities

Question 7

Colon Cancer

Very gradual (years) with v____ gastrointestinal (GI) symptoms.

Tumor may bleed intermittently, and patient may have (1). Changes in _____ habits, stool, or bl____ stool. H____-positive stool, dark ____ stool, and mass on abdominal palpation.

(1) gender, older patients (>___ years of age), patients with history of multiple p_____ or inflammatory bowel disease (IBD) such as (2), and post_____l women with (1) should be referred to GI specialist for colonoscopy and endoscopy.
(1) race have the highest incidence of colon cancer in the United States. The U.S. Preventive Services Task Force (USPSTF) recommends screening for colon cancer between ages of __ and __ years (Grade A recommendation).

Answer 7

Very gradual (years) with vague gastrointestinal (GI) symptoms.

Tumor may bleed intermittently, and patient may have iron-deficiency anemia. Changes in bowel habits, stool, or bloody stool. Heme-positive stool, dark tarry stool, and mass on abdominal palpation.

Males, older patients (>50 years of age), patients with history of multiple polyps or inflammatory bowel disease (IBD) such as Crohn’s disease (CD) or ulcerative colitis (UC), and postmenopausal women with iron-deficiency anemia should be referred to GI specialist for colonoscopy and endoscopy.

African Americans have the highest incidence of colon cancer in the United States. The U.S. Preventive Services Task Force (USPSTF) recommends screening for colon cancer between ages of 50 and 75 years (Grade A recommendation).

Question 8

Crohn’s Disease

CD is an IBD that may affect what part of the GI tract?

If ____ is involved, there is watery diarrhea without blood or mucus. If ____ is involved, there is bloody diarrhea with mucus.

During relapses, fever, anorexia, weight loss, dehydration, and fatigue with periumbilical to (1) quandrant abdominal pain occur. ____ formation and ___ disease occur only with CD (not UC). May palpate tender abdominal mass. R____ and r_____ are common. Higher risk of (2) colon. Risk of development of _____ is also increased, especially for patients treated with azathioprine. More common in (1) ethnicity.

Answer 8

CD is an IBD that may affect any part(s) of the GI tract, from mouth (canker sores), small or large intestine, rectum, and anus.

If ileum is involved, there is watery diarrhea without blood or mucus. If colon is involved, there is bloody diarrhea with mucus.

During relapses, fever, anorexia, weight loss, dehydration, and fatigue with periumbilical to RLQ abdominal pain occur. Fistula formation and anal disease occur only with CD (not UC). May palpate tender abdominal mass. Remissions and relapses are common. Higher risk of toxic megacolon and colon cancer. Risk of development of lymphoma is also increased, especially for patients treated with azathioprine. More common in Ashkenazi Jews.

Question 9

Ulcerative Colitis

IBD that affects what part?

_____ diarrhea with mucus (hematochezia) more common with UC than with CD. Severe “_____” cramping pain located on the ____ side of the abdomen with bl____ and gas that is exacerbated by food.

Relapses characterized by fever, anorexia, weight loss, and fatigue. Accompanied by (1)gia/ritis (15%–40%) that affect large joints, sacrum, and ankylosing spondylitis. May have ___-deficiency anemia or anemia of _____ disease. Disease has remissions and relapses. Increased risk of (2) colon.

Answer 9

IBD that affects the colon/rectum.

Bloody diarrhea with mucus (hematochezia) more common with UC than with CD. Severe “squeezing” cramping pain located on the left side of the abdomen with bloating and gas that is exacerbated by food.

Relapses characterized by fever, anorexia, weight loss, and fatigue. Accompanied by arthralgias and arthritis (15%–40%) that affect large joints, sacrum, and ankylosing spondylitis. May have iron-deficiency anemia or anemia of chronic disease. Disease has remissions and relapses. Increased risk of colon cancer. Risk of toxic megacolon.

Question 10

(1)

A gastrinoma located on the pancreas or the stomach; secretes gastrin, which stimulates high levels of acid production in the stomach. The end result is the development of multiple and severe ulcers in the stomach and duodenum. Complaints of epigastric to midabdominal pain. Stools may be a tarry color. Screening by serum fasting gastrin level. Refer to gastroenterologist.

Answer 10

Zollinger–Ellison Syndrome

Question 11

Route of Food or Drink from the Mouth

=

Answer 11

Esophagus → stomach (hydrochloric acid, intrinsic factor) → duodenum (bile, amylase, lipase) → jejunum → ileum → cecum → ascending colon → transverse colon → descending colon → sigmoid colon → rectum → anus

Question 12

Abdominal Contents

Which quadrants/areas of the abdomen are these organs located?

(1): Liver, gallbladder, ascending colon, kidney (right), pancreas (small portion); right kidney is lower than the left because of displacement by the liver

(1): Stomach, pancreas, descending colon, kidney (left)

(1): Appendix, ileum, cecum, ovary (right)

(1): Sigmoid colon, ovary (left)

(1) area: Bladder, uterus, rectum

Answer 12

• RUQ:* Liver, gallbladder, ascending colon, kidney (right), pancreas (small portion); right kidney is lower than the left because of displacement by the liver
• Left upper quadrant (LUQ):* Stomach, pancreas, descending colon, kidney (left)
• RLQ:* Appendix, ileum, cecum, ovary (right)
• LLQ:* Sigmoid colon, ovary (left)
• Suprapubic area:* Bladder, uterus, rectum

Question 13

Abdominal Maneuvers Indicating Acute Abdomen or Peritonitis

Answer 13

Psoas

Obturator

Rosving’s

Mcburney’s

Involuntary Guarding

Rebound Tenderness

Murphy’s

Carnett’s Test

Question 14

Psoas/Iliopsoas Sign

How to perform the maneuver?

+ Sign

What does a + sign indicate?

Answer 14

With patient in supine position, have patient raise right leg against the pressure of the professional’s hand resistance.

RLQ pain = + sign

Indicates irritation of iliopsoas group of hip flexors suggesting acute appendicitis, peritoneal irritation

Question 15

Obturator Sign

How to perform the maneuver?

+ Sign =

What does a + sign indicate?

Answer 15

Bend knee and rotate inward at hip joint

+ Sign = RLQ Pain with movement or flexion of hip

Acute Appendicitis, Acute abdomen or peritonitis

Question 16

Rosving’s Sign

How to perform the maneuver?

+ Sign =

What does a positive sign indicate?

Answer 16

Deep palpation of LLQ

+ Sign = Deep palpation of LLQ results in referred pain to the RLQ

Sign of peritonitis/acute abdomen

Question 17

McBurney’s Point

=

Answer 17

Palpation of RLQ illicits pain/tenderness - sign of possible acute appendicitis

(Area located between superior iliac crest and umbilicus in RLQ)

Question 18

Markle Test (Heel Jar)

=

Answer 18

The Markle Sign, Markle Test or Heel Drop Jarring Test is elicited in patients with intraperitoneal inflammation by having a patient stand on his or her toes and suddenly dropping down onto the heels with an audible thump, or jumping in place If abdominal pain is localized as the heels strike the ground or patient refuses to perform bc of pain - Markle Sign is positive

Question 19

Involuntary Guarding

=

Answer 19

With abdominal palpation, the abdominal muscles reflexively become tense or boardlike. Suspect acute or surgical abdomen. Refer to ED.

Question 20

Rebound Tenderness

=

Answer 20

Patient complains of worsening abdominal pain when hand is released after palpation of abdomen compared with the pain felt during deep palpation. Suspect acute or surgical abdomen. Refer to ED

Question 21

Murphy’s Maneuver

How to perform manuever?

+ Sign =

What does a + sign indicate?

Answer 21

Press deeply on the RUQ under the costal border during inspiration

Midinspiratory arrest is a positive finding (Murphy’s sign).

Positive with cholecystitis or gallbladder disease.

Question 22

Carnett’s Test

How to perform maneuver?

What is it used to test?

Results of test?

Answer 22

Patient is supine with arms crossed over their chest. Instruct patient to lift up shoulders from the table so that the abdominal muscles (rectus abdominus) tighten.

An abdominal maneuver that is used to determine if abdominal pain is from inside the abdomen or if it is located on the abdominal wall.

If source of pain is the abdominal wall, it will increase the pain; if the source is inside the abdomen, the pain will improve.

Question 23

Gastroesophageal Reflux Disease

=

• ___ percent of U.S. adults have gastroesophageal reflux disease (GERD).
• Diagnosis is based on h____ and clinical s______.
• Chronic GERD does what to the esophagus? (2)

Answer 23

Acidic gastric contents regurgitate from the stomach into the esophagus due to inappropriate relaxation of the lower esophageal sphincter.

• Forty percent of U.S. adults have gastroesophageal reflux disease (GERD).
• Diagnosis is based on history and clinical symptoms.
• Chronic GERD causes damage to squamous epithelium of the lower esophagus, and in about 10% of GERD patients may result in Barrett’s esophagus (a precancer), which increases risk of squamous cell cancer (cancer of the esophagus).

Question 24

Classic Case of GERD

Middle-aged to older adult complains of chronic heart____ of many years’ duration.

Symptoms associated with l___ and/or f__ meals that worsen when in what position?

Long-term history of self-medication with over-the-counter (OTC) ant____ or __-antagonists

Risk factors may include the chronic use of N____, as____, or al____.

Answer 24

Middle-aged to older adult complains of chronic heartburn of many years’ duration.

Symptoms associated with large and/or fatty meals that worsen when supine.

Long-term history of self-medication with over-the-counter (OTC) antacids and H2 antagonists.

Risk factors may include the chronic use of NSAIDs, aspirin, or alcohol.

Question 25

Objective Findings in GERD Acidic or s\_\_\_\_ odor to breath Reflux of sour acidic stomach contents, especially with overeating \_\_\_\_\_\_ tooth enamel (rear molars) due to increased hydrochloric acid Chronic \_\_\_\_-red throat (not associated with a cold) Chronic c\_\_\_\_\_\_\_\_

Answer 25

Acidic or sour odor to breath Reflux of sour acidic stomach contents, especially with overeating Thinning tooth enamel (rear molars) due to increased hydrochloric acid Chronic sore red throat (not associated with a cold) Chronic coughing

Question 26

GERD 1st Line Treatment First line treatment for mild/intermittent GERD = * Avoid ___ and/or high-\_\_\_meals, especially 3 to 4 hours before \_\_\_time. * Avoid foods or medications that ____ the lower esophageal sphincter or foods or medications that irritate the esophagus * Weight ______ if overweight (body mass index [BMI] \>\_\_\_) or obese. * Cease s\_\_\_\_\_. Smoking increases stomach ___ and lowers esophageal sphincter \_\_\_\_. If poor response, next step is to (1) and continue with lifestyle modifications.

Answer 26

**Lifestyle changes** for mild/intermittent GERD * Avoid large and/or high-fat meals, especially 3 to 4 hours before bedtime. * Avoid foods or medications that relax the lower esophageal sphincter or foods or medications that irritate the esophagus ([**Box 1**](https://examprepconnect.springerpub.com/app/family-nurse-practitioner-fnp#)). * Weight reduction if overweight (body mass index [BMI] \>25) or obese. * Cease smoking. Smoking increases stomach acid and lowers esophageal sphincter pressure. If poor response, next step is to prescribe medications and continue with lifestyle modifications.

Question 27

Foods that Worsen GERD Symptoms ## Footnote (1)-flavored gum or candy Ch\_\_\_\_\_ C\_\_\_\_\_\_ A\_\_\_\_\_ drinks Ca\_\_\_\_\_\_ beverages T\_\_\_\_\_ sauce Citrus drinks (e.g., ____ juice) F\_\_\_\_ foods

Answer 27

Peppermint- or mint-flavored gum or candy Chocolate Caffeine Alcoholic drinks Carbonated beverages Tomato sauce Citrus drinks (e.g., orange juice) Fatty foods

Question 28

Medications that Worsen GERD Symptoms ## Footnote \_\_\_\_\_ channel blockers N\_\_\_\_\_ Ni\_\_\_\_\_ \_\_\_\_-adrenergic receptor agonists Antich\_\_\_\_\_ I\_\_\_\_ supplements Bis\_\_\_\_\_\_\_\_\_ Quinidine Theophylline

Answer 28

Calcium channel blockers NSAIDs Nitrates Alpha-adrenergic receptor agonists Anticholinergics Iron supplements Bisphosphonates Quinidine Theophylline

Question 29

H2 Antagonists (3) First-line treatment for what type of symptoms/GERD? When should you take this medication?

Answer 29

**Ranitidine (Zantac) 300 mg** **Nizatidine (Axid) 300 mg** **Famotidine 40 mg at bedtime (Pepcid)** First-line treatment for mild-to-moderate symptoms or mild esophagitis. Should be taken at bedtime.

Question 30

Proton-pump inhibitors (PPIs) (4) Indicated for what type of GERD? When should you take this medication? Do not discontinue abruptly, why?

Answer 30

**Omeprazole (Prilosec) 20 mg once daily** **Esomeprazole (Nexium) 40 mg once daily** **Lansoprazole (Prevacid) 30 mg once daily** **pantoprazole (Protonix) 40 mg once daily.** For erosive esophagitis. Refer to gastroenterologist. Take 30 to 60 minutes before meals. Do not discontinue PPIs abruptly because can cause rebound symptoms/worsen symptoms- taper dose to wean

Question 31

Proton Pump Inhibitors (PPIs) Complications of Long Term Use **(1)** in postmenopausal women (interferes with calcium homeostasis) Acute interstitial \_\_\_\_\_ hypo\_\_\_\_\_\_ (1) infection Reduced absorption of \_\_\_\_\_

Answer 31

Osteoporosis and bone/hip fractures in postmenopausal women (interferes with calcium homeostasis) acute interstitial nephritis hypomagnesemia *C. difficile* infection Reduced absorption of iron.

Question 32

Antacids for GERD **(1) (Mylanta, Maalox)** **(1) (Tums, Caltrate)** **(1) (Gaviscon)** Minerals can bind with certain medications such as t\_\_\_\_\_ and lev\_\_\_\_\_\_\_

Answer 32

**Aluminum–magnesium–simethicone (Mylanta, Maalox)** **Calcium carbonate (Tums, Caltrate)** **Aluminum–magnesium (Gaviscon)** Minerals can bind with certain medications such as tetracycline and levothyroxine (Synthroid).

Question 33

GERD Treatment What should you do if patient has? Gold standard procedure = no relief after \_\_**-**\_\_ weeks of therapy high risk for _____ esophagus (long term GERD, white male \>50yo) Experiencing worrisome symptoms

Answer 33

Refer to GI specialist for upper endoscopy/biopsy (GOLD STANDARD) no relief after 4**-**8 weeks of therapy high risk for Barrett's esophagus (long term GERD, white male \>50yo) Experiencing worrisome symptoms

Question 34

Complications of GERD (3)

Answer 34

Barrett’s esophagus (a precancer for esophageal cancer) Esophageal cancer Esophageal stricture/scarring

Question 35

Worrisome Symptoms of GERD Refer to Gastroenterologist * Odynophagia = * Dysphagia = * Early \_\_\_\_\_ * Weight \_\_\_\_ * (1) anemia * gender (1) over (1) years old

Answer 35

* Odynophagia = pain with swallowing * Dysphagia = difficulty swallowing * Early Satiety * Weight Loss * Iron deficiency anemia (weight loss) * Male \>50 yo

Question 36

Clinical Pearls for GERD ## Footnote Any patient with at least a _____ or more history of chronic heartburn should be referred to a ______ for an ______ to rule out **(1)** Patients with Barrett’s esophagus have up to ___ times higher risk of _____ of the esophagus (\_\_\_\_\_\_ type).

Answer 36

Any patient with at least a decade or more history of chronic heartburn should be referred to a gastroenterologist for an endoscopy to rule out **Barrett’s** esophagus. Patients with Barrett’s esophagus have up to 30 times higher risk of cancer of the esophagus (adenocarcinoma type).

Question 37

Exam Tips **Barrett's Esophagus** = How do you diagnose Barrett's Esophagus? Know lifestyle factors to teach patient with GERD (e.g., no m\_\_\_\_, avoid c\_\_\_\_\_\_). **(1) sign =** edema and bruising of the subcutaneous tissue around the umbilicus indicates → (1) **(1) sign =** bruising/bluish discoloration of the flank area that may indicates → (1)

Answer 37

Barrett’s esophagus is a precancer (esophageal cancer). Diagnosed by upper endoscopy with biopsy. Know lifestyle factors to teach patient (e.g., no mints, avoid caffeine). **Cullen’s sign** = edema and bruising of the subcutaneous tissue around the umbilicus → **haemorrhagic pancreatitis** **Grey Turner’s sign** = bruising/bluish discoloration of the flank area that may indicate → **retroperitoneal hemorrhage/necrotizing pancreatitis**

Question 38

Exam Tips ## Footnote Classic pain of acute pancreatitis = How do you perform Rosving's maneuver? How do you perform Markle's maneuver? Positive Rosvings and Markle's Maneuver tests indicate what? How do you perform Psoas maneuver? How do you perform Obturator sign? Positive Psoas and Obturator signs indicate what?

Answer 38

Acute pancreatitis pain = severe midepigastric pain that radiates to midback (boring pain) **Rosving's maneuver** = pain in RLQ when palpating LLQ **Markle's maneuver** = having patient stand on toes and suddenly drop onto heels with an audible thump Positive Rosving's and Markles = **acute abdomen** **Psoas maneuver** = having the patient lie on his or her left side while the right thigh is flexed backward **Obturator sign** = internal rotation of right hip (ankle moves outward) with hip and knee flexed Positive Psoas and Obturator signs = **acute appendicitis**

Question 39

Exam Tips ## Footnote Worrisome symptoms for esophageal cancer **\_\_\_\_ on swallowing, early \_\_\_\_\_, and ____ loss** If patient needs treatment for GERD, start with **Rx (1)**; if poor relief or erosive esophagitis, step up to **Rx (1)**

Answer 39

Worrisome symptoms for esophageal cancer include pain on swallowing, early satiety, and weight loss. If patient needs treatment for GERD, **start with H2 antagonists**; if poor relief or erosive esophagitis, **step up to PPIs.**

Question 40

Acute Gastroenteritis Most common pathogens (1) (50-70%), (1) (15-20%), (1) (10-15%) Main symptom = Acute diarrhea = Persistent diarrhea = Chronic diarrhea =

Answer 40

Most common pathogens **viruses** (50-70%), **bacteria** (15-20%), **protozoans** (10-15%) Main symptom = Loose, watery diarrhea 3x or more per day Acute diarrhea = 1-2 days Persistent diarrhea = 2-4 weeks Chronic diarrhea = _\>_4 weeks

Question 41

(1) **_Acute onset of nausea and vomiting_ accompanied by _watery_ diarrhea that is _not bloody_. It is self-limited and of short duration, typically lasting 1 to 3 days.** Most common pathogens (2) One of these pathogens (1) can cause outbreaks in crowded areas such as (2)

Answer 41

Viral Gastroenteritis **_Acute onset of nausea and vomiting_ accompanied by _watery_ diarrhea that is _not bloody_. It is self-limited and of short duration, typically lasting 1 to 3 days.** Rotavirus, Norovirus Norovirus can cause outbreaks in crowded areas such as nursing homes, cruise ships

Question 42

**(1)** **Acute onset of high fever, _bloody_ diarrhea, severe abdominal pain with at least six stools in a 24-hour period.** Incubation period ranges from 1 to 6 hours if (1) Incubation period 1 to 3 days if (1)

Answer 42

**Bacterial Gastroenteritis** **Acute onset of high fever, bloody diarrhea, severe abdominal pain with at least six stools in a 24-hour period.** Incubation period ranges from 1 to 6 hours if due to contaminated food (enterotoxin) Incubation period 1 to 3 days if bacterial infection

Question 43

Bacterial Gastroenteritis Bacterial pathogens include *E\_\_\_\_ \_\_\_\_* *Sa\_\_\_\_\_*, *Sh\_\_\_\_*, *Ca\_\_\_\_\_*, *C. \_\_\_\_\_\_* (antibiotic use, recent hospitalization), and *L\_\_\_\_\_* (pregnant women 12-fold risk). Symptoms usually resolve in __ to __ days. (1) can prolong the length and/or severity of the disease(pregnant women 12-fold risk).

Answer 43

Bacterial pathogens include *Escherichia coli*, *Salmonella*, *Shigella*, *Campylobacter*, *C. difficile* (antibiotic use, recent hospitalization), and *Listeria* (pregnant women 12-fold risk). Symptoms usually resolve in 1 to 7 days. Antibiotics can prolong the length and/or severity of the disease

Question 44

(1) Symptoms develop within 7 days of exposure and typically last **≥7 days. It is usually watery diarrhea.** **Travelers’ diarrhea starts within 3 to 7 days after exposure and usually resolves in 5 days.** It is usually self-limited. **Pathogens (3)**

Answer 44

Protozoal Gastroenteritis *Giardia lamblia*, *Entamoeba histolytica*, and *Cryptosporidium*.

Question 45

Protozoal Gastroenteritis Risk Factors * Travel to (1) * Recent _____ use * _________ state * ____ care or resides in a _____ setting (e.g., nursing homes, institutions)

Answer 45

* Travel to developing countries * Recent antibiotic use * Immunocompromised state * Day care or resides in a crowded setting (e.g., nursing homes, institutions)

Question 46

Protozoal Gastroenteritis **Preventive Measures** * Drink (1), avoid (1) * Food and water precautions when traveling in \_\_\_\_-world countries * _____ hands frequently * Careful food \_\_\_\_\_, such as washing v\_\_\_\_ and f\_\_\_\_ * ______ vaccine (infants)

Answer 46

* Drink bottled water during foreign travel; avoid ice cubes * Food and water precautions when traveling in third-world countries * Wash hands frequently * Careful food preparation, such as washing vegetables and fruits * Rotavirus vaccine (infants)

Question 47

(1) A chronic functional disorder of the colon (normal colonic tissue) marked by **exacerbations** and **remissions** (spontaneous). Commonly exacerbated by excess **stress**. It may be classified as diarrhea-predominant or constipation-predominant. In some cases, it may alternate between the two

Answer 47

**Irritable Bowel Syndrome**

Question 48

Classic Case of IBS Young adult to middle-aged ____ complains of in\_\_\_\_\_\_ episodes of moderate-to-severe **cr\_\_\_\_\_** **pain in the lower abdomen**, especially in the **(1)** quadrant. **Bl\_\_\_\_\_ with fl\_\_\_\_\_\_**. **Relief obtained after \_\_\_\_\_\_\_**. Stools range from _____ to ______ or both types with \_\_creased frequency of bowel movements.

Answer 48

Young adult to middle-aged female complains of intermittent episodes of moderate-to-severe **cramping** pain in the lower abdomen, especially in the **LLQ**. **Bloating with flatulence. Relief obtained after defecation**. Stools range from diarrhea to constipation or both types with increased frequency of bowel movements.

Question 49

IBS Objective Findings ## Footnote A complete physical exam should be performed to exclude other causes. Vital signs are typically \_\_\_\_\_. * Abdominal exam*: ______ in lower quadrants during an \_\_\_\_\_\_\_. Otherwise the exam is \_\_\_\_\_. * Rectal exam*: Stool is _____ with no blood or pus. Stools are heme \_\_\_\_\_\_.

Answer 49

A complete physical exam should be performed to exclude other causes. Vital signs are typically normal. * Abdominal exam*: Tenderness in lower quadrants during an exacerbation. Otherwise the exam is normal. * Rectal exam*: Stool is normal with no blood or pus. Stools are heme negative. * PE all normal except for tenderness in lower quadrants during exacerbation*

Question 50

IBS Treatment _Diet Recommendations_ **Increase dietary _____ =** Supplement with below, start at low dose (causes gas) * (1) (Metamucil or Konsyl) * (1) (Citrucel) * (1) (Benefiber). ***Avoid \_\_\_-producing foods:*** Beans, onions, cabbage, high-fructose corn syrup. If poor response, use a trial diet of l\_\_\_\_\_ avoidance or g\_\_\_\_\_ avoidance.

Answer 50

**Increase dietary fiber.** Supplement fiber with, start at low dose (causes gas) * psyllium (Metamucil or Konsyl) * methylcellulose (Citrucel) * wheat dextrin (Benefiber). ***Avoid gas-producing foods:*** Beans, onions, cabbage, high-fructose corn syrup. If poor response, use a trial diet of lactose avoidance or gluten avoidance.

Question 51

IBS Pharm Treatment **(1)-****(2)Rx** *for abdominal pain* **(1)Rx** *for IBS with diarrhea* **(1)Rx** for *Severe diarrhea-predominant IBS* (warning _____ colitis, which can be fatal)

Answer 51

**Antispasmodics-****Dicyclomine (Bentyl) or Hyoscyamine** PRN *for abdominal pain* **Loperamide (Immodium)** before meals *for IBS with diarrhea* **Alosetron** for *Severe diarrhea-predominant IBS* (warning: ischemic colitis, which can be fatal)

Question 52

IBS Pharm Treatment *IBS with constipation* * Begin trial of **\_\_\_\_\_\_ supplements**, and **(1)Rx** (osmotic laxative) * If severe constipation = **1(Rx) or (1)Rx** (contraindicated in pediatric patients \<6 years, has caused death from dehydration)

Answer 52

* Begin trial of **fiber supplements**, and **polyethylene glycol** (osmotic laxative) * If severe constipation = **Lubiprostone or Linaclotide** (contraindicated in pediatric patients \<6 years, has caused death from dehydration)

Question 53

IBS Treatment Decrease life \_\_\_\_/\_\_\_\_ and offer treatment strategies. *Rule Out:* Amoebic, parasitic, or bacterial \_\_\_\_\_; _______ disease of the GI tract. Check stool for ova and p\_\_\_\_\_\_ (especially diarrheal stools) with c\_\_\_\_\_.

Answer 53

Decrease life anxiety/stress and offer treatment strategies. *Rule Out:* Amoebic, parasitic, or bacterial infections; inflammatory disease of the GI tract. Check stool for ova and parasites (especially diarrheal stools) with culture.

Question 54

IBS Clinical Pearl When should you not give antidiarrheal medications?

Answer 54

Do not give antidiarrheal medications if patient has **acute onset of bloody diarrhea, fever, abdominal pain, or pain that worsens with defecation because it may be caused by** ***E. coli*** O157:H7, shiga toxin–producing *E. coli* (STEC), amebiasis, *Salmonella, Shigella*, or other pathogens. **May need to go to ED.**

Question 55

Peptic Ulcer Disease (Gastric and Duodenal) ***(1)*** common cause of both duodenal and gastric ulcers Usually between \_\_\_-\_\_\_\_ years of age Which ulcer is more common? Do these ulcers always cause symptoms? Which ulcer has higher risk of malignancy?

Answer 55

***Helicobacter Pylori*** common cause of both duodenal and gastric ulcers Usually between 25-64 years of age Duodenal ulcers more common Most (70%) asymptomatic Gastric ulcers have higher risk of malignancy (up to 10%)

Question 56

PUD Causes ## Footnote Most Common Cause **(1)** (gram-negative bacteria) **Chronic (1) and (1) use** which disrupts ______ production, results in reduction of GI blood flow with reduction of protective mucus layer. It inhibits cyclooxygenase (COX 1 and COX 2) enzyme, which reduces production of prostaglandin. **(1) and (1) use** **Drug-induced PUD** can result from = bis\_\_\_\_\_\_, clop\_\_\_\_, antic\_\_\_\_\_\_, p\_\_\_\_\_\_supplements, cortico\_\_\_\_\_\_, ch\_\_\_\_therapeutic drugs, illicit drugs (crack \_\_\_\_\_\_).

Answer 56

Most Common Cause = **H. Pylori** (gram-negative bacteria) **Chronic NSAID and Aspirin use** which disrupts prostaglandin production, results in reduction of GI blood flow with reduction of protective mucus layer. It inhibits cyclooxygenase (COX 1 and COX 2) enzyme, which reduces production of prostaglandin. **Cigarette smoking and Alcohol use** **Drug-induced PUD** can result from = bisphosphonates, clopidogrel, anticoagulants, potassium supplements, corticosteroids, chemotherapeutic drugs, illicit drugs (crack cocaine).

Question 57

PUD Classic Case Adult complains of recurrent _______ pain, b\_\_\_\_\_/gn\_\_\_\_ pain, or ache (80%). Pain _____ by food and/or antacids (50%) with recurrence shortly after meals (\_\_\_\_ ulcer) and 2 to 4 hours after a meal (\_\_\_\_\_\_ ulcer). Pain also recurs when hungry or stomach is empty. Self-medicating with OTC antacid, H2 blocker, and/or PPI. May be taking NSAIDs or aspirin for chronic pain or prophylaxis against heart disease or stroke. Black or tarry stools (melena), red/maroon blood in stool (hematochezia), coffee-ground emesis, or iron-deficiency anemia indicates GI \_\_\_\_\_\_. If signs of shock (\_\_\_\_\_\_\_) are present with \_\_\_\_like abdomen and re\_\_\_\_\_ tenderness, call 911.

Answer 57

Adult complains of recurrent epigastric pain, burning/gnawing pain, or ache (80%). Pain relieved by food and/or antacids (50%) with recurrence shortly after meals (gastric ulcer) and 2 to 4 hours after a meal (duodenal ulcer). Pain also recurs when hungry or stomach is empty. Self-medicating with OTC antacid, H2 blocker, and/or PPI. May be taking NSAIDs or aspirin for chronic pain or prophylaxis against heart disease or stroke. Black or tarry stools (melena), red/maroon blood in stool (hematochezia), coffee-ground emesis, or iron-deficiency anemia indicates GI bleeding. If signs of shock (hemorrhage) are present with boardlike abdomen and rebound tenderness, call 911.

Question 58

PUD Worrisome Symptoms Early \_\_\_\_, an\_\_\_\_\_, an\_\_\_\_ (bleeding), recurrent v\_\_\_\_\_, hema\_\_\_\_, \_\_\_\_loss.

Answer 58

Early satiety, anorexia, anemia (bleeding), recurrent vomiting, hematemesis, weight loss.

Question 59

PUD Objective Findings ## Footnote * Abdominal exam =* * Hemoccult =*

Answer 59

* Abdominal exam:* Normal or mildly tender epigastric area during flare-ups. * Hemoccult:* Can be positive if actively bleeding.

Question 60

PUD Workup Labs (2) to check for bleeding *H.Pylori* Tests (3) Gold Standard (1)

Answer 60

CBC (iron-deficiency anemia), Fecal occult blood test (FOBT) *H.Pylori Tests = **Urea Breath Test\*, Stool antigen, Serology (titers)*** Gold Standard = Upper endoscopy and biopsy of gastric and/or duodenal tissue

Question 61

Urea Breath Test for H.Pylori Indicative of ____ *H. pylori* infection and is commonly used to document ______ of *H. pylori* after treatment. Use of ____ within 2 weeks of the test can interfere with results.

Answer 61

Indicative of active *H. pylori* infection and is commonly used to document eradication of *H. pylori* after treatment. Use of PPIs within 2 weeks of the test can interfere with results.

Question 62

Stool Antigen Test Can be used to confirm (1) and (1) Urea breath test and stool/fecal antigen test are _____ sensitive for active infection than serology/titers. Serology (Titers) immunoglobulin (Ig\_\_) levels elevated. Do antibodies indicate active infection?

Answer 62

Stool Antigen Test Can be used to confirm infection and posttreatment to document eradication. Urea breath test and stool/fecal antigen test are more sensitive for active infection than serology/titers. Serology (Titers) immunoglobulin (IgG) levels elevated. Presence of antibodies does not necessarily indicate current infection. *H. pylori* antibodies can be elevated for months to years.

Question 63

PUD What should you test for if the patient has *multiple severe ulcers or is unresponsive to treatment?* What test is needed to rule out gastric cancer and document healing of an ulcer?

Answer 63

Use fasting gastrin levels to rule out Zollinger–Ellison syndrome as needed. Requires an endoscopy to rule out gastric cancer and document healing of ulcer.

Question 64

Treatment for H.Pylori Negative Ulcers **Do you use antibiotics?** Stop use of (1), but if needs long-term use, use with (1) or misoprostol to decrease ulcer formation risk \_\_\_\_\_ cessation, stop drinking \_\_\_\_\_ Combine lifestyle changes with (1) or (1) antagonists (no antibiotics). * Duration of therapy is from __ to __ weeks. * If recurrent ulcers, poor response after 4 to 8 weeks of therapy, or suspect bleeding ulcer, refer to \_\_\_.

Answer 64

**NO ANTIBIOTICS NEEDED** Stop use of NSAIDs. If a patient needs long-term NSAIDs, ulcer formation risk can be decreased if combined with a PPI or misoprostol. Encourage smoking cessation. Stop drinking alcohol. Combine lifestyle changes with PPIs or H2 antagonists (no antibiotics). * Duration of therapy is from 4 to 8 weeks. * If recurrent ulcers, poor response after 4 to 8 weeks of therapy, or suspect bleeding ulcer, refer to GI.

Question 65

H2 Antagonists and PPIs for PUD *H2 antagonists:* * ______ (Zantac) 150 mg twice a day or 300 mg at \_\_\_\_ * _____ (Axid) 150 mg twice a day or 300 mg at \_\_\_\_\_ * _____ (Pepcid) 40 mg at \_\_\_\_\_ *PPIs*: * ______ (Prilosec) 20 mg daily * _______ (Nexium) 40 mg daily * ________ (Prevacid) 15–30 mg daily

Answer 65

*H2 antagonists:* * Ranitidine (Zantac) 150 mg twice a day or 300 mg at bedtime * Nizatidine (Axid) 150 mg twice a day or 300 mg at bedtime * Famotidine (Pepcid) 40 mg at bedtime *PPIs*: * Omeprazole (Prilosec) 20 mg daily * Esomeprazole (Nexium) 40 mg daily * Lansoprazole (Prevacid) 15–30 mg daily

Question 66

*Treatment for* *H. pylori**–Positive Ulcers* _Triple Therapy_ **(1) + (1) + (1) BID** **for __ days** If allergic to amoxicillin?

Answer 66

Clarithromycin + Amoxicillin + PPI BID for 14 days Metronidazole (Flagyl) 500mg if allergic to amoxicillin Clarithromycin (Biaxin) 500 mg + Amoxicillin 1 g + PPI BID x14 days

Question 67

*Treatment for* *H. pylori**–Positive Ulcers* _Quadruple Therapy_ (1)QID + (1)QID + (1)QID + (1)BID For ___ days

Answer 67

Bismuth Subsalicylate QID + Metronidazole QID + TetracyclineQID + PPIBID For 14 days Bismuth subsalicylate tab 600mg QID + Metronidazole tab 250mg QID + Tetracycline cap 500mg QID + Standard-dose PPI orally twice a day × 14 days

Question 68

Exam Tips for PUD Determine whether question is about *H. pylori*–\_\_\_\_ ulcers or *H. pylori*–\_\_\_\_\_ ulcers. *H. pylori*–positive ulcers require ____ for __ days plus ___ orally twice a day. Worrisome symptoms for esophageal ____ include an\_\_\_\_, early \_\_\_\_, an\_\_\_\_, recurrent \_\_\_\_\_, h\_\_\_temesis, and ____ loss.

Answer 68

Determine whether question is about *H. pylori*–negative ulcers or *H. pylori*–positive ulcers. *H. pylori*–positive ulcers require antibiotics for 14 days plus PPI orally twice a day. Worrisome symptoms for esophageal cancer include anorexia, early satiety, anemia, recurrent vomiting, hematemesis, and weight loss.

Question 69

Clinical Pearls for PUD ## Footnote \_\_\_\_\_\_ rate for untreated PUD is about 60%. High rates of _______ resistance (42%) in the United States. Avoid using clarithromycin therapy if there is high resistance in your area. Eradication rates in the United States using traditional triple therapy are now? PPIs vs. H2 antagonists for PUD?

Answer 69

Recurrence rate for untreated PUD is about 60%. High rates of clarithromycin resistance (42%) in the United States. Avoid using clarithromycin therapy if there is high resistance in your area. Eradication rates in the United States using traditional triple therapy are now \<80%. PPIs cure ulcers faster than H2 antagonists.

Question 70

Acute Diverticulitis **(1) = Small pouch-like herniations on the external surface of the colon** **Diverticulitis occurs when diverticula become \_\_\_\_\_; high risk of r\_\_\_\_ and bleeding, can be life-threatening** **Cause =** Higher incidence in ______ societies Majority of cases occur in what part of the colon (2)?

Answer 70

**Diverticula = Small pouch-like herniations on the external surface of the colon** **Diverticulitis occurs when diverticula become infected; high risk of rupture and bleeding, can be life-threatening** Cause = **chronic lack of dietary fiber** Higher incidence in Western societies (up to 50% of Americans age 60 years or older have diverticula in their colon) Majority of cases occur in left colon - descending colon and sigmoid

Question 71

Acute Diverticulitis Complications * Ab\_\_\_\_\_, p\_\_\_\_\_\_ with peritonitis and bleeding * Il\_\_\_\_, s\_\_\_\_\_, death What should you do if the patient has a Moderate-to-severe cases, dehydration, elderly, signs/symptoms of acute abdomen, high fever, comorbidities, or immunocompromised?

Answer 71

* Abscess, perforation with peritonitis and bleeding * Ileus, sepsis, death *Hospitalize*

Question 72

Classic Case of Acute Diverticulitis \_\_\_\_ aged adult presents with (1) quadrant abdominal pain that is (1) frequency and has been present for several days. If bowel ______ , may have nausea and/or vomiting or ileus due to peritonitis. Abdominal palpation reveals _____ on the LLQ. About half (50%) of patients have had one or more prior episodes of similar pain. Reports history of change in _____ habits; up to 50% will have constipation, and some will have diarrhea.

Answer 72

Elderly or older adult presents with LLQ abdominal pain that is constant and has been present for several days. If bowel obstruction, may have nausea and/or vomiting or ileus due to peritonitis. Abdominal palpation reveals tenderness on the LLQ. About half (50%) of patients have had one or more prior episodes of similar pain. Reports history of change in bowel habits; up to 50% will have constipation, and some will have diarrhea.

Question 73

Acute Diverticulitis vs. Diverticulosis ## Footnote * (1):* Physical exam is normal; no palpable mass; no tenderness. Diverticula can be visualized only by \_\_\_\_\_\_\_\_. * (1):* acute abdomen, positive for rebound, positive Rovsing’s sign, and boardlike abdomen, refer to \_\_\_.

Answer 73

* Diverticulosis:* Physical exam is normal; no palpable mass; no tenderness. Diverticula can be visualized only by colonoscopy. * Acute diverticulitis:* If acute abdomen, positive for rebound, positive Rovsing’s sign, and boardlike abdomen, refer to ED.

Question 74

Lab Findings in Acute Diverticulitis CBC = FOBT = What should you do if positive findings

Answer 74

CBC = reticulocytosis if acute bleeding and low Hgb/Hct, leukocytosis, neutrophilia (\>70%, shift to left (band forms) - presence of band forms signals severe bacterial infection FOBT = + if bleeding Send to ED

Question 75

Mild Acute Diverticulitis Treatment Uncomplicated Mild Cases * Treatment Setting = * Diet modification = * Pharm Therapy =

Answer 75

* Treatment Setting = can be treated outpatient * Diet modification = clear liquid diet * Pharm Therapy = antibiotics for 48-72 hours should improve

Question 76

Antibiotics for Diverticulitis (1) or (1) + (1) Treat for \_\_**-**\_\_ days

Answer 76

**Amoxicillin/Clavulanate** or **Ciprofloxacin + Metronidazole** Treat for **7-10** days Amoxicillin–clavulanate 875/125 mg orally twice a day or ciprofloxacin 750 mg twice a day *plus* metronidazole (Flagyl) 500 mg every 6 hours. Duration based on clinical response. Usually treat for 7 to 10 days.

Question 77

Acute Diverticulitis Treatment Opiates? Fiber? Probiotics?

Answer 77

NO! Opiates should be avoided during the acute phase because they increase intraluminal pressure and promote an ileus. NO! Increasing fiber intake is not recommended in the acute management of diverticulitis. Maybe - Probiotics have been used to prevent recurrences with mixed success.

Question 78

Acute Diverticulitis Treatment Follow Up ## Footnote *Close follow-up:* If no response in 48 to 72 hours or symptoms worsen (high fever, toxic), refer to \_\_\_; moderate-to-severe cases should be \_\_\_\_\_\_\_. Can be life-threatening if abscess \_\_\_\_, which will cause per\_\_\_\_\_, bacteremia, and septic \_\_\_\_\_.

Answer 78

*Close follow-up:* If no response in 48 to 72 hours or symptoms worsen (high fever, toxic), refer to ED; moderate-to-severe cases, hospitalize. Can be life-threatening if abscess ruptures, which will cause peritonitis, bacteremia, and septic shock.

Question 79

Chronic Therapy for Diverticulosis Diet modification = Misconception =

Answer 79

High-fiber diet with fiber supplementation such as psyllium (Metamucil) or methylcellulose (Citrucel) Avoidance of nuts, seeds, and popcorn is not evidence-based.

Question 80

Acute Pancreatitis **Acute inflammation of the pancreas secondary to many factors, such as _____ abuse, \_\_\_\_stones (cholelithiasis), elevated ______ levels, infections** * Pancreatic enzymes become activated inside pancreas, causing auto\_\_\_\_\_. * Varies in severity from mild to life-threatening/death. * (1) are responsible for 40% to 70% of cases; 25% to 35% are caused by (1). * Elevated _______ (\>\_\_\_\_ mg/dL) at very high risk for acute pancreatitis.

Answer 80

**Acute inflammation of the pancreas secondary to many factors, such as alcohol abuse, gallstones (cholelithiasis), elevated triglyceride levels, infections** * Pancreatic enzymes become activated inside pancreas, causing autodigestion. * Varies in severity from mild to life-threatening/death. * Gallstones (includes microlithiasis) are responsible for 40% to 70% of cases; 25% to 35% are caused by alcohol. * Elevated triglycerides (\>800 mg/dL) at very high risk for acute pancreatitis.

Question 81

Classic Case of Acute Pancreatitis Adult patient complains of acute onset of fever, nausea, and vomiting that is associated with rapid onset of **abdominal pain that radiates to the \_\_\_\_\_\*,** located in the _____ region. Abdominal exam reveals g\_\_\_\_\_ and t\_\_\_\_\_ over the epigastric area or the upper abdomen. Positive **(2) signs**. May have ileus and signs and symptoms of shock. Refer patient to ED.

Answer 81

Adult patient complains of acute onset of fever, nausea, and vomiting that is associated with rapid onset of abdominal **pain that radiates to the midback**, located in the epigastric region. Abdominal exam reveals guarding and tenderness over the epigastric area or the upper abdomen. **Positive Cullen’s and Grey Turner’s sign.** May have ileus and signs and symptoms of shock. Refer patient to ED.

Question 82

Acute Pancreatitis Objective Findings ## Footnote ***(1) sign**:* Bluish discoloration around umbilicus (hemorrhagic pancreatitis) ***(1) sign**:* Bluish discoloration on the flank area (hemorrhagic pancreatitis) \_\_\_\_\_\_ bowel sounds (ileus), j\_\_\_\_, g\_\_\_\_, and \_\_\_\_\_like upper abdomen if peritonitis

Answer 82

***Cullen’s sign**:* Bluish discoloration around umbilicus (hemorrhagic pancreatitis) ***Grey Turner’s sign**:* Bluish discoloration on the flank area (hemorrhagic pancreatitis) Hypoactive bowel sounds (ileus), jaundice, guarding, and boardlike upper abdomen if peritonitis

Question 83

Pancreatitis Workup Elevated pancreatic (1) such as serum (3) Elevated liver/bile ducts (3), b\_\_\_\_\_, leuko\_\_\_\_\_ Abdominal (1) and (1)

Answer 83

Elevated pancreatic enzymes such as serum amylase, lipase, and trypsin Elevated aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma glutamyl transferase (GGT), bilirubin, leukocytosis Abdominal ultrasound and CT

Question 84

Acute Pancreatitis Complications ## Footnote Serious complications such as il\_\_\_, s\_\_\_\_, sh\_\_\_\_, multiorgan \_\_\_\_, death D\_\_\_\_\_

Answer 84

Serious complications such as ileus, sepsis, shock, multiorgan failure, death Diabetes

Question 85

(1) Infection from a Gram-positive, spore-forming anaerobic bacillus that releases toxins that produce clinical disease. The classic symptom is watery diarrhea a few days after starting antibiotic treatment due to changes in intestinal flora caused by antibiotics.

Answer 85

***Clostridium Difficile*****–Associated Diarrhea**

Question 86

***Clostridium Difficile*****–Associated Diarrhea** Antibiotics most likely to cause C.Diff (4) Most cases occur in ______ patients; may also occur in institutionalized patients (\_\_\_\_\_facilities). Transmission route =

Answer 86

Clindamycin (Cleocin), Fluoroquinolones, Cephalosporins, Penicillins Most cases occur in hospitalized patients; may also occur in institutionalized patients (nursing facilities). It is spread by fecal–oral contact.

Question 87

*Clostridium Difficile*–Associated Diarrhea Risk Factors ## Footnote Prior or current systemic _____ therapy \_\_\_\_\_ age Hos\_\_\_\_\_\_\_\_ Cancer \_\_\_\_\_\_\_\_\_

Answer 87

Prior or current systemic antibiotic therapy Advanced age Hospitalization Cancer chemotherapy

Question 88

C. Diff Classic Case \_\_\_\_ aged patient who is currently on ______ or has recently completed a course of antibiotics. History of h\_\_\_\_\_\_. Acute onset of diarrhea with lower abdominal cr\_\_\_\_ and p\_\_\_, anorexia, nausea, and low-grade fever. *C. difficile* colitis has a ____ recurrence rate (25%), so ask about previous episodes.

Answer 88

Adult to elderly patient who is currently on antibiotics or has recently completed a course of antibiotics. History of hospitalization. Acute onset of diarrhea with lower abdominal cramping and pain, anorexia, nausea, and low-grade fever. *C. difficile* colitis has a high recurrence rate (25%), so ask about previous episodes.

Question 89

C.Diff Diarrhea Labs ## Footnote **(1)** Testing for *C. difficile* **(1)** for *C. difficile* toxins. CBC with _____ (\>15,000 cells/μL), metabolic profile, electrolytes, serum creatinine, blood urea nitrogen (BUN). Should you repeat stool testing to confirm cure? Should you treat asymptomatic patients?

Answer 89

**Nucleic acid amplification testing (NAAT)** for *C. difficile* of a single stool sample. **Stool assay (by enzyme-linked immunosorbent assay)** for *C. difficile* toxins. CBC with leukocytosis (\>15,000 cells/μL), metabolic profile, electrolytes, serum creatinine, blood urea nitrogen (BUN). Not recommended to repeat stool testing for test of cure is not recommended. *C. difficile* toxin may persist despite clinical response to treatment. Do not treat asymptomatic patients

Question 90

C. Diff Treatment **First line =** **Avoid what medication?** Anticipate _____ in 20% to 25% of patients. Consider (1) in recurrent disease. Moderate evidence that (1) are effective for those with intact immune systems.

Answer 90

First line = **Vancomycin 125mg PO QID x10 days** Avoid antimotility agents (loperamide) in patients with bloody diarrhea or antibiotic-associated colitis. Anticipate relapse in 20% to 25% of patients. Consider fecal microbiota transplant in recurrent disease. Moderate evidence that probiotics are effective for those with intact immune systems.

Question 91

C. Diff Treatment Recommendations for Fluid intake and Diet? Do you need a specific type of diet? Isolation precautions =

Answer 91

Rehydration (Naturalyte, Rehydralyte), increase fluids, eat food as tolerated. Early oral refeeding is encouraged, regular diet. Restricted diets such as BRAT (bananas, rice, applesauce, toast) not necessary. Contact precautions.

Question 92

Clinical Pearl C.Diff Should you use alcohol based hand wipes or soap and water to protect against C.diff?

Answer 92

Handwashing with soap and water is more effective against C. difficile than alcohol-based hand wipes.

Question 93

Screening Test for Hepatitis A **(1)** **= acute infection, patient is contagious, no immunity yet** **(1)** = **lifelong immunity, no virus present and is not infectious, can remain detectable for decades** How do receive immunity to hepatitis A? (2)

Answer 93

***IgM Antibody Hepatitis A Virus (IgM Anti-HAV)*** **= acute infection, patient is contagious, no immunity yet** ***IgG Antibody Hepatitis A Virus (IgG Anti-HAV)*** = **lifelong immunity, no virus present and is not infectious, can remain detectable for decades** *How:* History of native hepatitis A infection or vaccination with hepatitis A vaccine (Havrix)

Question 94

Screening for Hepatitis B **(1)** = active infection and is infectious **(1)** = ongoing infection, appears at onset of symptoms in acute Hep B and persists for life **(1)** = immunity, due to past infection or immunization **(1) =** marker of actively replicating hep B virus, highly infectious, indicates chronic hepatitis

Answer 94

***Hepatitis B Surface Antigen (HBsAg)*** = active infection and is infectious ***Total Hepatitis B Core Antibody (Anti-HBc)*** = ongoing infection, appears at onset of symptoms in acute Hep B and persists for life ***Hepatitis B Surface Antibody (Anti-HBs)*** = immunity, due to past infection or immunization ***Hepatitis B “e” Antigen (HBeAg)*** **=** marker of actively replicating hep B virus, highly infectious, indicates chronic hepatitis

Question 95

Hepatitis C Screening **(1)** Up to 85% of cases become \_\_\_\_\_\_. Does a positive Hep C antibody always mean immunity? What should you if HCV antibody is positive? Then what should you do if the HCV RNA is positive?

Answer 95

***Hepatitis C Virus Antibody (Anti-HCV)*** ## Footnote Up to 85% of cases become carriers. Unlike hepatitis A and B, a positive anti–hepatitis C virus (HCV; antibody) does not always mean that the patient has recovered from the infection and developed immunity; it may instead indicate current infection because up to 85% of cases become carriers. If HCV antibody test is positive: Order **HCV RNA** to rule out chronic infection. If HCV RNA positive, then **patient has hepatitis C;** refer to **GI specialist for liver biopsy/treatment.**

Question 96

Hepatitis D Screening **(1) and/or (1)** You can only have Hepatitis D when? If you do have infection with both Hep B and D leaves the patient at increased risk for? Transmission Route = When should you suspect HDV infection?

Answer 96

***Antibody Hepatitis D Virus and/or Hepatitis D Virus RNA (HDV RNA)*** Requires presence of Hep B to get infection, is a coinfection Infection with both hepatitis B and hepatitis D increases the risk of fulminant hepatitis, cirrhosis and severe liver damage; low prevalence in the United States Transmission Route = blood and bodily fluids (Transmission by sex, sharing needles, birth to an infected mother, needle sticks, semen, saliva) Suspect HDV infection in any person with positive hepatitis B antigen (HBsAg) who has severe symptoms of hepatitis or acute exacerbations

Question 97

Hepatitis A * Transmission Route =* * Labs* (2)= Hepatitis A is ______ to the public health department. Is there a chronic carrier state?

Answer 97

* Transmission:* Transmitted via fecal and oral route from contaminated food or drink, households, sex. * Labs:* IgM anti–hepatitis A virus (HAV) or NAAT/polymerase chain reaction (PCR) test for hepatitis A virus RNA. Hepatitis A is reportable to the public health department. No chronic or carrier state exists for hepatitis A.

Question 98

Hepatitis A * Symptoms =* * Treatment =* * Prevention =* Avoid hepatotoxic foods and drugs such as = ac\_\_\_\_\_\_, al\_\_\_\_\_/ethanol, st\_\_\_\_, iso\_\_\_\_, and ______ teas. Avoid working in \_\_\_\_-related jobs for 1 week after onset of infection.

Answer 98

* Symptoms =* Acute onset of fever, headache, malaise, anorexia, nausea, vomiting, diarrhea, abdominal pain, dark urine, jaundice. Bilirubin levels \>3 mg/dL, ALT levels \>200 IU/L. * Treatment* = Self-limiting infection; treatment is symptomatic * Prevention =* vaccine available (Havrix) and recommended for travelers to areas where hepatitis A is endemic. Avoid hepatotoxic foods and drugs such as = acetaminophen, alcohol/ethanol, statins, isoniazid, and herbal teas. Avoid working in food-related jobs for 1 week after onset of infection.

Question 99

Hepatitis B * Transmission =* * Vaccination =* Hepatitis B can either be (1) or (1), or it can be a ______ infection.

Answer 99

* Transmission =* Horizontal transmission via sexual activity (semen, vaginal secretions, and saliva), blood, blood products, organs. Vertical transmission occurs from mother to infant. * Vaccination =* Three total doses given during infancy (at birth, 1 month, 6 months); adults require three doses. Hepatitis B can either be acute and self-limiting, or it can be a chronic infection.

Question 100

Acute Hepatitis B Treatment =

Answer 100

Hepatitis B Immune Globulin (HBIG) + start 3 dose Hep B Vaccine series if no previous vaccine history

Question 101

Chronic Hepatitis B Treatment =

Answer 101

1st line treatment for Chronic Hep B Antiviral agents + Pegylated interferone alpha (PEG-IFN-a) Refer to gastroenterologist

Question 102

Hepatitis C * Transmission =* * Most common cause of (1) in the US* Approximately 75% to 85% of people who become infected with hepatitis C will develop chronic infection.

Answer 102

*Transmission =* Mostly Blood and sometimes bodily fluids - Transmitted via sharing needles, blood transfusions before 1992, mother to infant (vertical transmission), needle-stick injuries in healthcare settings. Less common, spread by sexual contact, sharing personal items (razors or toothbrushes) Most common cause of liver cancer and liver transplantation in the United States Approximately 75% to 85% of people who become infected with hepatitis C will develop chronic infection.

Question 103

Hepatitis C *High-risk groups:* (1) users, h\_\_\_philiacs, anyone with history of frequent ______ , and persons born between 1945 and 19\_\_. The USPSTF recommends routine \_\_\_-time HCV screening for ___ adults ages __ to __ years \_\_\_\_\_ acute cases of hepatitis C to the health department.

Answer 103

*High-risk groups:* Intravenous drug users, hemophiliacs, anyone with history of frequent transfusions, and persons born between 1945 and 1965. The USPSTF recommends routine one-time HCV screening for *all* adults ages 18 to 79 years Report acute cases of hepatitis C to the health department.

Question 104

Hepatitis C Treatment Can you treat Hep C by yourself? Why or Why not? Advise patient to not share? *Treatment =*

Answer 104

Refer to Gastroenterology because Hep C has the highest risk of chronic hepatitis infection and cirrhosis (30%). Cirrhosis markedly increases the risk of liver cancer or liver failure Advise patient not to share razors, toothbrushes, and nail clippers and to cover cuts and sores. *Treatment =* Refer to gastroenterologist. Highly effective oral antiviral regimens are available, and the vast majority of hepatitis C patients can be treated.

Question 105

Hepatitis B Practice Question ## Footnote * Hepatitis B surface antigen (HBsAg):* Negative * Anti-HBs:* Positive * Hepatitis B “e” antigen (HBeAg):* Negative

Answer 105

Immune to Hep B Because due presence of hep B surface antibodies - due to either vaccination or recovered from native hepatitis B infection Negative surface antigen = not an active infection Positive hepatitis B surface antibodies = immune Negative Hep B “e” antigen = not actively replicating or a carrier

Question 106

Viral Hepatitis Practice Question ## Footnote * HBsAg*: Positive * HBeAg:* Positive * Anti-HBs:* Negative * Anti-HAV:* Positive * Anti-HCV:* Negative

Answer 106

+ Hep B infection and Immunity to Hep A Current Hepatits B infectio (HbsAg positive) Chronic carrier of hepatitis B (both HBsAg and HBeAg are positive) Presence of antibodies to hepatitis A (anti-HAV); patient either had a previous hepatitis A infection or received the hepatitis A vaccine (has immunity This patient is a carrier of the hepatitis B virus; if the HBeAg is positive and highly reactive, it means that the patient is contagious.

Question 107

Liver Function Tests (4) biomarkers of hepatic injury

Answer 107

AST ALT Alkaline phosphatase Bilirubin

Question 108

**Aspartate Aminotransferase (AST)** *Normal:* __ to __ U/L Also known as *(1) (SGOT)* Present in the liver, h\_\_\_\_ muscle, sk\_\_\_\_ muscle, k\_\_\_\_, and br\_\_\_\_ Elevated in h\_\_\_\_\_, cirr\_\_\_\_, nonalcoholic ____ liver disease, _____ abuse, drugs (e.g., acetaminophen, statins), ______ infarction, \_\_\_\_\_nucleosis

Answer 108

*Normal:* 0 to 35 U/L Also known as *serum glutamic oxaloacetic transaminase (SGOT)* Present in the liver, heart muscle, skeletal muscle, kidney, and brain Elevated in hepatitis, cirrhosis, nonalcoholic fatty liver disease, alcohol abuse, drugs (e.g., acetaminophen, statins), myocardial infarction, mononucleosis

Question 109

**Alanine Aminotransferase (ALT)** *Normal:* Males, __ to __ U/L; Females: __ to \_\_U/L Also known as *(1) (SGPT)* Found ______ in the liver; a positive finding indicates liver \_\_\_\_\_\_\_ Compared to AST? Rapid \_\_creases in AST and ALT levels together with rise of serum _____ and prolongation of \_\_\_

Answer 109

*Normal:* Males, 10 to 40 U/L; Females: 8 to 35 U/L Also known as *serum glutamic pyruvic transaminase (SGPT)* Found mainly in the liver; a positive finding indicates liver inflammation More specific for hepatocellular injury than AST Rapid decreases in AST and ALT levels together with rise of serum bilirubin and prolongation of PT

Question 110

AST/ALT Ratio What ratio is indicative of alcohol abuse?

Answer 110

Ratio of 2 or higher is indicative of alcohol abuse So AST will be 2x greater than ALT

Question 111

(1) **An indicator of continuous heavy drinking for several weeks or longer (about 70 drinks/week).** Found in many organs of the body but mainly on the liver, kidneys, and pancreas. Can become elevated with medications (phenytoin, barbiturates), biliary disease, liver cancer or metastases, pancreatitis. During alkaline phosphatase elevation, check this, and if it is elevated, the source is the \_\_\_\_\_.

Answer 111

**Gamma-Glutamyl Transferase (GGT)** **An indicator of continuous heavy drinking for several weeks or longer (about 70 drinks/week).** GGT is found in many organs of the body but mainly on the liver, kidneys, and pancreas. Can become elevated with medications (phenytoin, barbiturates), biliary disease, liver cancer or metastases, pancreatitis. During alkaline phosphatase elevation, check this, and if it is elevated, the source is the liver.

Question 112

(1) Enzyme derived from **bone**, **liver**, gallbladder, kidneys, GI tract, and **placenta** The **highest amounts** come from the **bones** and the **liver**. During the third trimester of pregnancy, elevated levels come from the **placenta**. Alkaline phosphatase levels vary with age; in general, higher levels are seen during growth spurts (physiologic osteoblastic activity) in children and teens. Elevated in biliary obstruction, cholestasis, bone malignancy/metastasis, healing **fractures**.

Answer 112

**Alkaline Phosphatase (ALP)**

Question 113

(1) An acute liver inflammation with multiple causes, including viral infection, hepatotoxic drugs (e.g., statins), excessive alcohol intake, medications, and toxins.

Answer 113

Acute Hepatitis

Question 114

Classic Case of Acute Hepatitis Adult complains of a new onset of fatigue, anorexia, nausea, malaise, and \_\_\_\_-colored urine for several days. Both sclerae have a ______ tinge (ic\_\_\_). Skin is **j\_\_\_\_\_\_\_**. May have **\_\_\_\_\_**-**colored stools**. May have (1) quadrant abdominal pain

Answer 114

Adult complains of a new onset of fatigue, anorexia, nausea, malaise, and dark-colored urine for several days. Both sclerae have a yellowish tinge (icteric). Skin is **jaundiced**. May have **clay**-**colored stools**. May have RUQ abdominal pain

Question 115

Acute Hepatitis Objective Findings ## Footnote Skin and sclerae = *Liver =*

Answer 115

Skin and sclerae have a yellow tinge (jaundiced or icteric). *Liver:* Tenderness over the liver occurs with percussion and deep palpation.

Question 116

Acute Hepatitis Labs ## Footnote *ALT and AST:* Levels are elevated up to \_\_× normal during the acute phase of the illness. Other liver function tests (LFTs), such as serum (1) and (1), may be elevated.

Answer 116

*ALT and AST:* Levels are elevated up to 10× normal during the acute phase of the illness. Other liver function tests (LFTs), such as serum bilirubin and GGT, may be elevated.

Question 117

Acute Hepatitis Treatment Remove and treat the _____ (if possible). Avoid hepatotoxic agents such as _____ drinks, rx (1), and rx (1) (e.g., pravastatin [Pravachol]). Treatment is s\_\_\_\_\_\_\_. Chronic hepatitis _ and _ are managed by gastroenterologists.

Answer 117

Remove and treat the cause (if possible). Avoid hepatotoxic agents such as alcoholic drinks, acetaminophen, and statins (e.g., pravastatin [Pravachol]). Treatment is supportive. Chronic hepatitis B and C are managed by gastroenterologists.

Question 118

Exam Tips * There will be a serology question. You will have to figure out what type of viral hepatitis the patient has (A, B, or C). It is usually hepatitis B. **HBs\_\_\_-positive status always means an infected patient (new infection or chronic).** * PCR tests are not ______ tests. They test for presence of viral \_\_\_\_. A positive result means that the virus is \_\_\_\_\_\_. This test can be performed for ______ disease such as hepatitis C or HIV.

Answer 118

* There will be a serology question. You will have to figure out what type of viral hepatitis the patient has (A, B, or C). It is usually hepatitis B. HBsAg-positive status always means an infected patient (new infection or chronic). * PCR tests are not antibody tests. They test for presence of viral RNA. A positive result means that the virus is present. This test can be performed for diagnosing disease such as hepatitis C or HIV.

Question 119

Exam Tips * Hepatitis ___ has highest risk of cirrhosis and liver cancer. * Screening test for hepatitis C virus is called the (1). If positive, next step is to order (1). If positive, patient has hepatitis C. * GGT is elevated in liver disease and _____ obstruction. A “\_\_\_\_” elevation in the GGT is a sensitive indicator of possible \_\_\_\_\_\_.

Answer 119

* Hepatitis C has highest risk of cirrhosis and liver cancer. * Screening test for hepatitis C virus is called the HCV antibody (anti-HCV). If positive, next step is to order HCV RNA test. If positive, patient has hepatitis C. * GGT is elevated in liver disease and biliary obstruction. A “lone” elevation in the GGT is a sensitive indicator of possible alcoholism.

Question 120

Exam Tips * **(1)\*** is normally elevated during the teen years due to bone growth. The ALP may also be elevated in bone disorders such as vitamin D deficiency, Paget’s disease, and bone cancer. A \_\_\_\_, which would be elevated with liver disease, may be drawn to differentiate between liver disease and bone disorders. * A person must have (1) to become infected with hepatitis D. There is no ____ for hepatitis D, but hepatitis B _____ will prevent acquisition of hepatitis D.

Answer 120

* **Alkaline phosphatase (ALP)** is normally elevated during the teen years due to **bone growth**. May also be elevated in bone disorders such as vitamin D deficiency, Paget’s disease, and bone cancer. A GGT, which would be elevated with liver disease, may be drawn to differentiate between liver disease and bone disorders. * A person must have hepatitis B to become infected with hepatitis D. There is no vaccine for hepatitis D, but hepatitis B vaccination will prevent acquisition of hepatitis D.

Question 121

Exam Tips * **(1)** is more sensitive to liver damage than **(1)**. * AST is also found in other organs such as the (1) and (1) system. AST and ALT may be elevated and may reflect acute liver injury or inflammation. However, these levels may be _____ in chronic liver disease, such as cirrhosis. * For mild cases of GERD, _____ management and (1)rx or (1)rx. For moderate-to-severe esophagitis, first line is (1)rx. * *Acute ________ symptoms:* Amylase and lipase are sensitive tests

Answer 121

* ALT is more sensitive to liver damage than AST. * AST is also found in other organs such as the heart and skeletal system. AST and ALT may be elevated and may reflect acute liver injury or inflammation. However, these levels may be normal in chronic liver disease, such as cirrhosis. * For mild cases of GERD, lifestyle management and antacids or H2 antagonists. For moderate-to-severe esophagitis, first line is PPIs. * *Acute pancreatitis symptoms:* Amylase and lipase are sensitive tests used for pancreatic inflammation (pancreatitis).