GI Flashcards
.
GI
Oral naloxegol is a peripherally acting μ-opioid receptor antagonist that is FDA-approved for the treatment of opioid-induced constipation in adults with chronic noncancer pain.
GI
he patient has hepatitis B virus (HBV) infection in the immune-tolerant phase, which can be determined by the likely vertical transmission and the patient’s young age, positive hepatitis B e antigen (HBeAg), high viral load, and normal aminotransferase levels.
Patients with hepatitis B infection in the immune-tolerant phase require serial monitoring of aminotransferase levels.
Patients with HBV infection in the immune-active, HBeAg-positive and reactivation, HBeAg-negative phases require treatment if the alanine aminotransferase level is elevated.
GI
Patients with HBV infection are at increased risk for hepatocellular carcinoma, even in the absence of cirrhosis. Patients from Southeast Asia should undergo hepatocellular carcinoma surveillance with ultrasonography starting at age 40 years for men and at age 50 years for women, and patients from sub-Saharan Africa should begin at age 20 years.
GI
Aspirin for secondary prophylaxis in patients with established cardiovascular disease should be continued after colonoscopy with polypectomy.
GI
Nonalcoholic fatty liver disease is the most common cause of abnormal liver test results in the United States.
The finding of a hyperechoic liver on ultrasonography is also consistent with NAFLD.
GI
The diagnosis of primary biliary cholangitis (PBC) is generally made on the basis of a cholestatic liver enzyme profile in the setting of a positive antimitochondrial antibody test
Autoimmune hepatitis is typically accompanied by higher autoantibody titers positive anti–smooth muscle antibody test
GI
Pseudoachalasia is caused by a tumor at the gastroesophageal junction infiltrating the myenteric plexus causing esophageal motor abnormalities; symptoms, barium-imaging and manometric findings, and endoscopic appearance are similar to achalasia.
Typical achalasia has an insidious onset and long duration of symptoms, often measured in years, before patients seek medical attention.
GI
A low-FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, And Polyols) diet can reduce abdominal pain and bloating and improve stool consistency, frequency, and urgency in patients with diarrhea-predominant irritable bowel syndrome.
Linaclotide is a peripherally acting guanylate cyclase-C activator approved by the FDA for the treatment of IBS-C
GI
Patients with dysphagia associated with regurgitation of undigested food should be evaluated with a barium esophagram for the presence of a Zenker diverticulum.
Treatment is reserved for symptomatic patients and endoscopic diverticulectomy is favored where surgical expertise is available.
GI
Esophageal manometry is used when there is concern for a motility disorder, such as achalasia. Patients with motility disorders commonly report dysphagia to liquids or both solids and liquids; this patient’s dysphagia to solid food does not suggest a motility disorder.
GI
Hepatopulmonary syndrome is a complication of cirrhosis caused by dilation of the pulmonary vasculature in the setting of advanced liver disease and portal hypertension. A high alveolar-arterial oxygen gradient results from functional shunting. Patients with hepatopulmonary syndrome usually have a preexisting diagnosis of liver disease and present with shortness of breath
The diagnosis of hepatopulmonary syndrome is made by demonstrating an arterial oxygen tension less than 80 mm Hg (10.7 kPa) breathing ambient air, or an alveolar-arterial gradient of 15 mm Hg (2 kPa) or greater, along with evidence of intrapulmonary shunting on echocardiography with agitated saline or macroaggregated albumin study.
GI
Cholecystectomy is the definitive treatment for acalculous cholecystitis in stable patients. However, this patient is now hemodynamically unstable and, therefore, requires a temporizing cholecystostomy tube to allow time for her to stabilize and for gallbladder inflammation to improve before cholecystectomy.
A hepatobiliary iminodiacetic acid scan may be used when ultrasonography is equivocal, and it would show nonopacification of the gallbladder in cases of cholecystitis.
GI
In patients requiring NSAIDs, an evidence-based treatment strategy to prevent recurrent NSAID-induced peptic ulcers is the use of a cyclooxygenase-2 selective NSAID plus a proton pump inhibitor.
GI
Patients with small (<10 mm) hyperplastic polyps on baseline colonoscopic examination should undergo surveillance colonoscopy in 10 years.
Sessile serrated polyps (also known as sessile serrated adenomas) and traditional serrated adenomas are both neoplastic and are precursors to colorectal cancer; they should be completely excised.
guidelines recommend managing large (>10 mm) hyperplastic polyps as if they are sessile serrated polyps.
GI
A 3-year surveillance interval is recommended for patients who have three or more adenomas (or sessile serrated polyps) found on baseline colonoscopy, one adenoma larger than 10 mm in size, or an adenoma with any degree of villous or high-grade dysplasia.
A surveillance interval of 5 years is recommended for patients with two or fewer adenomas (or sessile serrated polyps) found on baseline colonoscopy and for patients with a first-degree relative with colon cancer diagnosed at an age younger than 60 years.
GI
Patients who have cholangitis with evidence of biliary obstruction should be treated with antibiotic therapy and biliary decompression with endoscopic retrograde cholangiopancreatography.
In patients with evidence of biliary obstruction (as seen in this patient’s findings on ultrasonography) and more than mild disease, biliary decompression with ERCP is an essential component of therapy
Obstruction is typically indicated by a dilated bile duct and persistently elevated liver enzyme levels.
GI
Esophageal stricture in patients with eosinophilic esophagitis requires treatment with endoscopic dilation when symptoms do not respond to medical therapy.
Endoscopy with dilation is the most appropriate treatment for this patient, who has eosinophilic esophagitis, refractory symptoms of dysphagia despite fluticasone therapy, and the finding of an esophageal stricture on endoscopy
GI
Microscopic colitis is a cause of nonbloody, watery diarrhea in older adults and is diagnosed by colonoscopy with random biopsies from multiple colonic segments
Microscopic colitis is more common in older persons and does not cause endoscopically visible inflammation..
Microscopic colitis is associated with other autoimmune diseases such as diabetes mellitus and psoriasis
GI
Small intestinal bacterial overgrowth (SIBO) causes diarrhea, often with bloating, flatulence, and weight loss. Several conditions can predispose patients to SIBO due to effects on stomach acid, intestinal transit, or disruption of normal antibacterial defense mechanisms. Gastric bypass surgery is an increasingly common cause of SIBO. The absence of malabsorption symptoms and weight loss make this diagnosis unlikely.
GI
Almost all patients (>90%) with autoimmune pancreatitis enter clinical remission in response to glucocorticoids.
Based on his typical symptom of painless jaundice and the characteristic “sausage-shaped” pancreas on imaging, the patient has type 1 autoimmune pancreatitis, a frequent manifestation of IgG4 disease
Endoscopic retrograde cholangiopancreatography with bile-duct stenting is usually not required in patients with autoimmune pancreatitis because most patients’ symptoms respond quickly to oral prednisone
GI
The fetus should be delivered immediately upon recognition of acute fatty liver of pregnancy.
Women with acute fatty liver of pregnancy typically present with a 1- to 2-week history of nausea and vomiting, right-upper-quadrant or epigastric pain, headache, jaundice, anorexia, and/or polyuria and polydipsia.
GI
The finding of a gallbladder polyp larger than 1 cm in size, or a polyp of any size associated with gallstones, is an indication for cholecystectomy even if the patient is asymptomatic.
Cholecystectomy is indicated for this patient with a gallbladder polyp and gallstones because of the increased risk for gallbladder cancer when the two conditions coexist.
In a patient with an 8-mm gallbladder polyp in the absence of gallstones or primary sclerosing cholangitis, repeat ultrasonography in 6 months would be indicated.
GI
After eradication therapy for Helicobacter pylori infection, eradication should be confirmed using the urea breath test or fecal antigen test.
Testing to confirm eradication should be pursued in all cases of identified and treated Helicobacter pylori infection because of the established risks for peptic ulcer disease and gastric malignancy in patients with chronic H. pylori infection
Unless upper endoscopy is indicated for other reasons, noninvasive testing modalities (the urea breath test or the fecal antigen test) are more appropriate for confirmation of eradication or assessment for reinfection.
GI
Same-admission cholecystectomy reduces rates of gallstone-related complications compared with cholecystectomy after hospital discharge for patients with mild gallstone pancreatitis.
GI
Indications for endoscopic retrograde cholangiopancreatography in patients with primary sclerosing cholangitis are bacterial cholangitis, increasing jaundice, increasing pruritus, or a dominant stricture on imaging.
Symptoms of bacterial cholangitis, increasing jaundice, and pruritus can signify strictures that may improve with dilation or stenting, or, alternatively, removing sludge or stone debris in the bile ducts via ERCP
GI
IgG4 levels should be checked in patients with a new diagnosis of presumed PSC because IgG4 cholangitis is a steroid-responsive condition, whereas PSC is not.
GI
Red-flag symptoms such as rectal bleeding with iron deficiency anemia, abdominal pain, and weight loss should prompt evaluation by colonoscopy for colorectal cancer regardless of the patient’s age or the presence of bleeding hemorrhoids.
GI
Narcotic bowel syndrome, also known as opiate-induced gastrointestinal hyperalgesia, is a centrally mediated disorder of gastrointestinal pain characterized by a paradoxical increase in abdominal pain with increasing doses of opioids.
GI
Treatment of chronic pancreatitis–related persistent pain should proceed in a stepwise approach beginning with lifestyle modifications (discontinue alcohol and cigarettes) and the use of simple analgesics (acetaminophen, NSAIDs).
GI
Sofosbuvir and ledipasvir are direct-acting antiviral agents used to treat hepatitis C virus (HCV) infection and would be an appropriate choice for mild HCV-related PAN.
Mild hepatitis B virus–related polyarteritis nodosa is treated with antiviral agents like entecavir.
GI
Enteral nutrition is preferred in patients with acute pancreatitis because of the benefit of maintaining a healthy gut mucosal barrier to prevent translocation of bacteria.
Total parenteral nutrition (TPN) is discouraged in patients with acute pancreatitis because the mucosal barrier is not maintained when patients are NPO for prolonged periods, which may lead to higher rates of bacterial translocation into necrotic pancreatic tissu
GI
Primary prophylactic antibiotic therapy is indicated for patients at high risk for the development of spontaneous bacterial peritonitis, including patients with very low ascitic-fluid protein levels and those with advanced liver failure.
Criteria for patients at high risk include an ascitic-fluid total protein level less than 1.5 g/dL (15 g/L) in conjunction with any of the following: serum sodium level less than or equal to 130 mEq/L (130 mmol/L), serum creatinine level greater than or equal to 1.2 mg/dL (106.1 µmol/L), blood urea nitrogen level greater than or equal to 25 mg/dL (8.9 mmol/L), serum bilirubin level greater than or equal to 3 mg/dL (51.3 µmol/L), or Child-Turcotte-Pugh class B or C cirrhosis.
GI
Rapid gastric emptying of hyperosmolar chyme into the small intestine after partial gastric resection can lead to postprandial vasomotor symptoms, abdominal pain, and diarrhea, collectively known as dumping syndrome.
Common early symptoms of dumping symptoms are palpitations, tachycardia, diaphoresis, and lightheadedness with abdominal pain and diarrhea presenting within 30 minutes of eating.
Small intestinal bacterial overgrowth (SIBO) is an excess number and alteration in type of bacteria cultured from the small intestine. Unlike in dumping syndrome, symptoms are not immediately related to eating and are not associated with prominent vasomotor symptoms such as palpitations, tachycardia, diaphoresis, and lightheadedness.
GI
Linaclotide is a peripherally acting guanylate cyclase-C receptor agonist that is FDA approved for the treatment of chronic idiopathic constipation in adults with symptoms refractory to first-line therapies.
Osmotic laxatives include magnesium hydroxide, lactulose, sorbitol, and polyethylene glycol (PEG); clinical trials have demonstrated the superiority and safety of PEG.
GI
Pregnant women who have hepatitis B virus DNA levels greater than 200,000 IU/mL at 24 to 28 weeks’ gestation should be treated with tenofovir to prevent vertical transmission during delivery.
Guidelines recommend treatment with lamivudine, telbivudine, or tenofovir for the prevention of vertical transmission in pregnant women who have HBV DNA levels greater than 200,000 IU/mL at 24 to 28 weeks’ gestatio
GI
Once endoscopic hemostasis has been achieved in a patient with gastrointestinal bleeding, anticoagulation should be reinitiated, and in most cases, this can be done on the same day as the procedure.
GI
Anti–tissue transglutaminase IgA antibody testing is the best screening test for celiac disease.
GI
After treatment of colon cancer, patients should undergo surveillance colonoscopy 1 year after diagnosis.
If the colonoscopy is normal, the AGA recommends repeat examination in 3 years; ASCO recommends repeat examination in 5 years. If normal, colonoscopy should be repeated every 5 years thereafter until the benefit of continued surveillance is outweighed by risks and diminished life expectancy.
If neoplasms are detected during any follow-up examination, then the surveillance interval should be adjusted based on polyp size, number, and histology
GI
Surgical resection is the best management option for high-risk cystic lesions of the pancreas, such as intraductal papillary mucinous neoplasms that involve the main duct.
GI
Angiography is used to diagnose the cause of obscure gastrointestinal bleeding when more common sources are not found on routine upper and lower endoscopy. It is also used for treatment, such as embolization, when a bleeding source has been identified.
GI
Secretory and osmotic diarrhea can often be distinguished by clinical history. Patients with secretory diarrhea may pass liters of stool daily, causing severe dehydration and electrolyte disturbances, with persistent stooling despite fasting. Patients with osmotic diarrhea often have stool volumes of less than 1 L/d and have cessation of stooling when they are fasting.
GI
Secretory and osmotic diarrhea can often be distinguished by clinical history. Patients with secretory diarrhea may pass liters of stool daily, causing severe dehydration and electrolyte disturbances, with persistent stooling despite fasting. Patients with osmotic diarrhea often have stool volumes of less than 1 L/d and have cessation of stooling when they are fasting.
GI
Colonoscopy results in Crohn disease show patchy distribution of mucosal inflammatory changes with “skip areas” of normal intervening mucosa, and biopsy results for involved mucosa show features of chronicity (distorted and branching colonic crypts).
Because ulcerative colitis typically involves the rectum, tenesmus, urgency, rectal pain, and fecal incontinence are common. Patients with ulcerative colitis have distorted and branching colonic crypts on biopsy, but the distribution of inflammation begins in the rectum and progresses up the colon in a continuous and symmetric pattern, without skip areas.
GI
Patients with uncomplicated diverticulitis should undergo colonoscopy 1 to 2 months after the episode of acute diverticulitis, when colonic inflammation has resolved.
GI
Patients with newly diagnosed pernicious anemia should be evaluated for gastric adenocarcinoma and gastric carcinoid with upper endoscopy and gastric biopsy.
GI
Anal fissures are tears in the anoderm below the dentate line that can be seen on inspection of the perianal area, often unaided by the use of an anoscope.
The most effective treatment approach for anal fissure is daily warm-water sitz baths and the use of the bulk laxative psyllium.
GI
Patients with multiple fundic gland polyps found at a young age should be evaluated for familial adenomatous polyposis.
Colonoscopy to rule out FAP is recommended in patients younger than age 40 years with dysplastic or numerous fundic gland polyps.
GI
Approximately 5% of patients with inflammatory bowel disease will develop primary sclerosing cholangitis during the course of their disease, typically presenting as cholestatic liver injury with a characteristic imaging study showing bile duct strictures and dilations (“string of beads”).
In most patients, PSC presents as a stricturing process in the medium to large bile ducts, readily identifiable by MR cholangiopancreatography
GI
Patients with a clinical diagnosis of gastroesophageal reflux disease should start an empiric trial of a proton pump inhibitor in conjunction with lifestyle and dietary changes, with no further testing.
Upper endoscopy is indicated in patients with alarm symptoms, such as dysphagia or weight loss, and in patients whose symptoms do not respond to a PPI.
GI
All hospitalized patients with inflammatory bowel disease should be given pharmacologic venous thromboembolism prophylaxis with subcutaneous heparin.
GI
Ambulatory pH testing can be a helpful diagnostic test in patients with suspected extraesophageal manifestations of gastroesophageal reflux disease.
extraesophageal symptoms of GERD include asthma, globus sensation, hoarseness, throat clearing, and chronic laryngitis. It appears that the laryngopharynx is more sensitive to the erosive effects of acid, and small amounts of reflux may produce symptoms. The selection of a diagnostic test to confirm or exclude laryngopharyngeal reflux is controversial. Ambulatory pH testing, if positive, can help to confirm the diagnosis of GERD and supports the diagnosis of laryngopharyngeal reflux. Negative ambulatory pH testing suggests that the patient does not have GERD and that proton pump inhibitor therapy should be discontinued
Medications that decrease kidney perfusion, including NSAIDs, ACE inhibitors, and angiotensin receptor blockers, should be discontinued in patients with ascites.
Acute liver failure is an indication for immediate referral to a liver transplantation center.
Acute liver failure is defined by the manifestation of hepatic encephalopathy within 26 weeks of developing symptoms of liver disease. The development of jaundice was this patient’s first symptom of liver disease. Within 6 weeks, he developed coagulopathy, with an INR of 2.6, as well as symptoms of hepatic encephalopathy (confusion and asterixis).
GI
Combined mesalamine therapy (oral and topical) is superior for induction of remission in mild to moderately active ulcerative colitis compared with oral or topical therapies alone.
. The distribution of ulcerative colitis is generally divided into proctitis (involving the rectum only), left-sided colitis (inflammation does not extend beyond the splenic flexure), and pancolitis (inflammation extends above the splenic flexure).
Patients younger than age 60 years presenting with dyspepsia should first undergo a noninvasive test for Helicobacter pylori followed by eradication therapy if testing is positive.
Upper endoscopy should be performed routinely in patients older than age 60 years with persistent dyspeptic symptoms. Clinicians may treat a minority of patients older than age 60 years with empirical therapy instead of endoscopy, provided the risk of upper gastroenterologic malignancy is low.
GI
The mainstay of therapy for amebic liver abscesses is antibiotic therapy, such as metronidazole, plus a luminal agent, such as paromomycin, to eradicate the coexisting intestinal infection.
GI
Chronic bloody diarrhea and abdominal discomfort are typical presenting symptoms of inflammatory bowel disease; endoscopic findings help distinguish ulcerative colitis from Crohn disease.
The endoscopic description of inflammation beginning at the anorectal verge and extending proximally in a continuous fashion with transition to normal mucosa at splenic flexure is consistent with left-sided ulcerative colitis.
Crohn disease characteristically has a patchy progression pattern resulting in “skip lesions” and may spare the rectum, making Crohn colitis less likely in this case.
GI
Wilson disease should be considered in all patients younger than age 40 years who have unexplained liver disease.
hen Wilson disease causes acute hepatitis, usually in young patients, the sudden release of copper from liver cells can also induce hemolytic anemia. In this patient with evidence of hepatic encephalopathy, hemolytic anemia, low alkaline phosphatase level, and unconjugated bilirubinemia, the diagnosis of Wilson disease should be considered. The serum ceruloplasmin level is used to test for Wilson disease.
The clinical presentation of achalasia consists of dysphagia to both solids and liquids.
Patients with achalasia who are at high surgical risk should be treated with endoscopic botulinum toxin injection.
Pneumatic dilation is the most effective nonsurgical treatment and is more cost-effective than surgical myotomy, but it is associated with serious complications, such as esophageal perforation. Therefore, patients who are not surgical candidates should not undergo endoscopic dilation treatment of achalasia.
GI
In patients with atypical chest pain, a cardiac cause must be ruled out before starting treatment for gastroesophageal reflux disease.
GI
The relapsing, remitting variant of hepatitis A viral infection is characterized by multiple clinical or biochemical relapses with spontaneous improvement within months to 1 year without intervention.
GI+.
Long-term proton pump inhibitor (PPI) therapy for uncomplicated gastroesophageal reflux disease should be given at the lowest effective dose possible, and consideration should be given to reducing or stopping PPI therapy at least once a year.
Maintenance PPI therapy is recommended for patients with GERD who continue to have symptoms after the initial course of a PPI is discontinued, and for those who have erosive esophagitis or Barrett esophagus.
GI
The mainstay of therapy for intrahepatic cholestasis of pregnancy is ursodeoxycholic acid, which is associated with alleviated symptoms and improved liver test abnormalities.
GI
Isolated right-colon ischemia may be a warning sign of acute mesenteric ischemia caused by embolism or thrombosis of the superior mesenteric artery and should be evaluated using CT angiography.
GI
Olmesartan causes medication-induced enteropathy that can mimic refractory celiac disease.
In 2013, the FDA issued a warning that olmesartan medoxomil can cause intestinal symptoms known as sprue-like enteropathy and approved labeling changes to include this concern. The enteropathy may develop months to years after starting olmesartan. Drug-associated enteropathy can mimic refractory celiac disease with findings of villous atrophy and increased intraepithelial lymphocytes in the first part of the duodenum.
GI
Endoscopic ablation should be considered after confirmation of dysplasia by a second expert pathologist.
GI
Barrett esophagus with low-grade dysplasia should be treated with endoscopic ablation therapy in patients without significant comorbidities.
In the past, guidelines recommended a surveillance endoscopy in 6 months for patients with low-grade dysplasia. However, more recent guidelines recommend that patients with minimal comorbidities undergo endoscopic ablation therapy for permanent eradication of Barrett esophagus
GI
Giardia lamblia infection is a common parasitic infection that occurs most often among children, child care workers, and backpackers or campers who drink untreated water from lakes, rivers, or wells. Treatment options include tinidazole, metronidazole, and nitazoxanide.
A 24-hour 5-hydroxyindoleacetic acid measurement is used to evaluate for carcinoid tumors. Up to 85% of patients with gastrointestinal carcinoid syndrome experience intermittent flushing. In addition to flushing, diarrhea is prominent in most patients and is related to rapid intestinal transit time.
GI
The diagnosis of gastroparesis requires the presence of specific symptoms, absence of mechanical outlet obstruction, and objective evidence of delay in gastric emptying into the duodenum.
GI
The mainstay of therapy for variceal hemorrhage is endoscopic therapy, and adjunctive therapies such as antibiotic therapy improve outcomes.
he mainstay of therapy for variceal hemorrhage is endoscopic therapy. Antibiotic therapy is an important adjunctive therapy for variceal bleeding because bacterial infection occurs in 30% to 40% of patients within 1 week of variceal bleeding
GI
Individuals with a first-degree relative with colon cancer or an advanced adenoma diagnosed at an age younger than 60 years, or two or more first-degree relatives with colon cancer or advanced adenoma diagnosed at any age, should begin colon cancer screening at age 40 years (or 10 years earlier than the youngest age at which colon cancer was diagnosed in a first-degree relative, whichever is first).
GI
Patients with cirrhosis and who meet the Milan criteria (up to three hepatocellular carcinoma tumors ≤3 cm or one tumor ≤5 cm) are best treated with liver transplantation and have excellent 5-year survival rates.
GI
A diagnosis of hepatocellular carcinoma can be made in a patient with cirrhosis in the presence of lesions larger than 1 cm that enhance in the arterial phase and have washout of contrast in the venous phase.
Biopsy of the lesion is not indicated in this patient. In the context of cirrhosis, a lesion larger than 1 cm with contrast enhancement in the arterial phase and portal venous washout meets radiologic criteria for hepatocellular carcinoma and, therefore, does not require a lesion biopsy.
GI
Eosinophilic esophagitis typically presents in young men with symptoms of dysphagia and in patients with a history of food allergies, eczema, and asthma.
Pill-induced esophagitis has been observed with medications including alendronate, quinidine, tetracycline, doxycycline, potassium chloride, ferrous sulfate, and mexiletine.
GI
Incidentally found gallstones with no associated symptoms and no complications require no further intervention.
GI
the classic “herald bleed” of aortoenteric fistula: a brisk bleed associated with hypotension that stops spontaneously and then is followed later by massive gastrointestinal hemorrhage. An aortoenteric fistula is a communication between the aorta and the gastrointestinal tract, most commonly located in the distal duodenum, especially the third portion, because the duodenum is fixed and located just anterior to the aorta. The possibility of an aortoenteric fistula must be considered in a patient with previous aortic graft surgery who presents with gastrointestinal bleeding.
GI
Patients with uncomplicated diverticulitis should be treated conservatively with oral antibiotics.
Physical examination findings include fever, left-lower-quadrant tenderness, and/or a lower abdominal or rectal mass. If clinical features are highly suggestive of diverticulitis, imaging studies are unnecessary. If the diagnosis is not clear or if an abscess is suspected (severe pain, high fever, palpable mass), CT imaging is indicated
intravenous antibiotics are appropriate in patients who cannot take oral medications or who have complicated diverticulitis, such as abscess or fistula formation
gi
Fecal loading (excess stool in the colon) with resultant overflow diarrhea is a common cause of fecal incontinence in elderly patients, particularly those who are hospitalized or have degenerative neurologic disorders.
Before treating the diarrhea, it is essential to determine whether the diarrhea is due to overflow from fecal loading (excess stool in the colon). An abdominal radiograph is a simple, safe, and inexpensive diagnostic test
GI
Ischemic colitis is a low-flow state of the colon occurring most frequently in the left colon and characterized by moderate, left-sided, cramping abdominal pain followed by bloody diarrhea.
GI
Anti–tumor necrosis factor agents such as infliximab are effective in inducing and maintaining remission in moderate to severe Crohn disease.
GI
Patients with Lynch syndrome should begin screening colonoscopy between ages 20 and 25 years or 2 to 5 years before the earliest age of colorectal cancer diagnosis in the family, whichever comes first, and colonoscopy should be repeated every 1 to 2 years if the baseline examination is normal.
GI
A history of multiple family members with gastric cancer, particularly before age 50 years, or multiple family members with lobular breast cancer with or without gastric cancer, suggest the possibility of hereditary diffuse gastric cancer and the need for upper endoscopy and testing for mutations of the CDH1 gene.
GI
In patients with well-preserved liver function, drug-induced liver injury should be managed with discontinuation of the offending medication and observation until resolution of symptoms occurs.
GI
Upper-endoscopy screening for duodenal cancer in patients with familial adenomatous polyposis should begin at onset of colonic polyposis or at age 25 to 30 years, whichever comes first.
GI
The presence of three or more adenomas, any adenoma greater than or equal to 1 cm in size, or any adenoma with villous features or high-grade dysplasia has been associated with increased risk for metachronous neoplasia (multiple primary tumors developing at different time intervals), warranting a 3-year surveillance interval.
GI
The presence of three or more adenomas, any adenoma greater than or equal to 1 cm in size, or any adenoma with villous features or high-grade dysplasia has been associated with increased risk for metachronous neoplasia (multiple primary tumors developing at different time intervals), warranting a 3-year surveillance interval.
GI
Mixed cryoglobulinemia arising from chronic hepatitis C viral infection resolves after treatment and eradication of the virus.
Other direct-acting antiviral agents that could be used interchangeably to treat genotype 1 HCV include grazoprevir-elbasvir; paritaprevir-ritonavir, ombitasvir, and dasabuvir; glecaprevir-pibrentasvir; sofosbuvir-daclatasvir; and sofosbuvir-velpatasvir.
The first step in the management of microscopic colitis is to discontinue a potentially causative medication, after which supportive treatment with antidiarrheal agents such loperamide can be tried, with budesonide recommended for patients whose symptoms do not respond.
GI
For women with asymptomatic hepatic adenomas smaller than 5 cm in size, estrogen-containing oral contraceptive agents should be discontinued, and follow-up liver imaging is recommended every 6 months for at least 2 years.
GI
Capsule endoscopy is the most appropriate test to evaluate patients for causes of small-bowel bleeding after negative upper endoscopy and colonoscopy.
GI
Chronic hepatitis B viral infection in the immune-active, hepatitis B e antigen–positive phase should be treated with tenofovir or entecavir to decrease hepatic inflammation and the risk for progression to fibrosis.
GI
For Helicobacter pylori infection that persists after eradication therapy, the salvage therapy regimen should consist of different antibiotics from those used in the initial, unsuccessful regimen.
GI
In patients with end-stage liver disease and portal hypertension, hepatorenal syndrome is characterized by the development of oliguric kidney failure, bland urine sediment, and marked sodium retention (edema, ascites, low urinary sodium).
GI
Asymptomatic patients with walled-off necrosis of the pancreas require no intervention.
GI
Patients with hepatitis C viral infection who achieve sustained virologic response have a reduced risk for hepatocellular carcinoma; regardless of virologic response, ultrasonographic surveillance is recommended for patients with stage 3 or stage 4 fibrosis.
In a patient with suspected Achalasia, dysphagia for solids and liquids and regurgitation of
undigested food, what is the first test in evaluation?
barium esophagography; shows “bird’s beak” narrowing of the GE junction
In a patient with suspected Achalasia, dysphagia for solids and liquids and regurgitation of
undigested food, after barium esophagropahy is done, what is the next test in evaluation?
upper endoscopy to rule out adenocarcinoma (pseudoachalasia) at the GE
junction
In a patient with suspected Achalasia, dysphagia for solids and liquids and regurgitation of
undigested food, what text confirms diagnosis? ?
esophageal manometry confirms diagnosis by documenting absence of peristalsis and incomplete relaxation of the LES with swallows
If the patient has a history of travel to South America and with suspected Achalasia, dysphagia for solids and liquids and regurgitation of
undigested food, what diagnosis should be suspected?
If the patient has a history of travel to South America, suspect Chagas disease as
the cause of achalasia.
Which clinical syndrome is associated with this pic?
The “bird’s beak” finding reflects narrowing of the distal esophagus and is
characteristic of achalasia.
What is the first-line therapy for achalasia?
Laparoscopic myotomy of the LES is the first-line therapy for achalasia.
If a patient has Less than X number of days of watery diarrhea they require no testing or
microscopic assessment?
Healthy patients with watery diarrhea of less than 3 days’ duration require no testing or
microscopic assessment.
After how long should watery diarrhea be evaluated with stool testing?
If diarrhea does not resolve in 1 week, evaluation is
recommended with stool testing for common bacterial pathogens and toxins, including
Clostridioides difficile.
Under what scenarios should pts have diagnostic
assessment of their stool to guide antimicrobial use?
Patients with mucoid or bloody diarrhea (dysentery), fever, or suspected sepsis and
those who are immunocompromised or require hospitalization should have diagnostic
assessment of their stool to guide antimicrobial use.
which GI infection develops most often in patients with AIDS, but outbreaks also occur in immunocompetent patients, often related to public swimming pools?
Cryptosporidiosis
Which GI infection can mimic appendicitis or Crohn disease?
Yersinia enterocolitica colitis can mimic appendicitis or Crohn disease.
Patients with bloody diarrhea (dysentery) and temperatures >101 °F should be treated with empirically with what antibiotic after
microbiologic assessment?
Dysentery with temperatures >101 °F should be treated with empiric azithromycin (after
microbiologic assessment).
what is the Treatment for travel-associated diarrhea?
Treat travel-associated diarrhea with empiric azithromycin.
what is the tx for Diarrhea caused by parasites (Giardia lamblia or Entamoeba histolytica)?
Diarrhea caused by parasites (Giardia lamblia or Entamoeba histolytica) requires therapy
with metronidazole, tinidazole, or nitazoxanide.
Should you treat/choose antibiotics for EHEC colitis?
Do not choose antibiotics for EHEC colitis.
can you choose loperamide or diphenoxylate for acute diarrhea with fever or
blood in the stool?
NO! Do not choose loperamide or diphenoxylate for acute diarrhea with fever or
blood in the stool. Both agents are associated with HUS in EHEC colitis and toxic
megacolon in C. difficile infection.
Which clinical syndrome is associated with acute liver injury complicated by encephalopathy and
coagulopathy in patients without previous cirrhosis?
Acute liver failure refers to acute liver injury complicated by encephalopathy and
coagulopathy in patients without previous cirrhosis.
Which 4 drugs are most commonly associated with Drug-induced liver injury ?
Drug-induced liver injury is most commonly caused by acetaminophen, antibiotics
(particularly amoxicillin-clavulanate), and antiepileptic medications (phenytoin and
valproate).
What is the most common cause of acute liver failure?
Acetaminophen overdose, the most
common cause of acute liver failure
Which clinical syndrome is associated with Sudden elevation of serum AST and ALT levels
up to 20×?
Acetaminophen overdose
How is acetaminophen overdose managed?
Measure serum acetaminophen
level and use nomogram to
determine whether
N-acetylcysteine is indicated.
Which clinical syndrome is associated with Outbreaks of acute liver failure associated with
foods such as raspberries and scallions?
Acute HAV infection
Which clinical syndrome is associated with Acute elevation of AST to >1000 U/L while
hospitalized?
Episode of acute hypotension with
associated liver hypoperfusion
Which clinical syndrome is associated with Acute elevation of liver enzymes and hemolysis
in a young patient, Kayser-Fleischer rings,
history of psychiatric disorders, and/or
athetoid movements?
Wilson disease
How is Wilson disease managed?
Measure serum copper and
ceruloplasmin levels and urine
copper excretion.
Which clinical syndrome is associated with this pic?
Wilson disease. A Kayser-Fleischer ring in the cornea is bracketed with arrowheads.
What is the treatment For patients with acute liver failure?
For patients with acute liver failure, choose:
* immediate contact w/liver transplantation center
* N-acetylcysteine for confirmed or suspected acetaminophen poisoning
* lactulose for any degree of encephalopathy
In patients with acute liver failure and altered
mental status, what evaluation should be next?
Head CT should be performed in patients with acute liver failure and altered
mental status to rule out cerebral edema or intracranial hemorrhage.
What is the diagnostic criteria for pancreatitis?
Diagnosis of acute pancreatitis requires at least two of the following criteria:
* acute onset of upper abdominal pain
* serum amylase or lipase increased ≥3× ULN (lipase is more specific and sensitive
than amylase)
* findings suggesting pancreatitis on cross-sectional imaging (ultrasonography, CT, MRI)
What is the most common complication of acute pancreatitis.?
Pancreatic pseudocysts are the most common complication of acute pancreatitis.
All patients with acute pancreatitis require what before leaving the hospital?
All patients with acute pancreatitis require abdominal ultrasonography to evaluate the
biliary tract for obstruction.
when is CT of the abdomen is indicated for pancreatitis?
CT of the abdomen is indicated only if the pancreatitis is severe, it lasts longer than 48
hours, or complications are suspected.
Pertaining to pancreatitis, which findings are
worrisome for abscess, pseudocyst, or necrotizing pancreatitis?
Uncomplicated pancreatitis is not typically associated with rebound abdominal
tenderness, absent bowel sounds, high fever, or melena. When these findings are
present, consider abscess, pseudocyst, or necrotizing pancreatitis.
Besides pancreatitis, what else can Mildly increased amylase values represent?
Mildly increased amylase values can also be caused by kidney disease, intestinal
ischemia, appendicitis, and parotitis.
For treatment of pancreatitis, In addition to vigorous IV hydration and pain relief, when should oral feeding resume?
oral feeding when nausea, vomiting, and abdominal pain resolve
For treatment of pancreatitis, In addition to vigorous IV hydration and pain relief, when should enteral jejunal feedings start if oral feeding not tolerated?
enteral jejunal feedings within 72 hours if oral feeding not tolerated
For treatment of pancreatitis, In addition to vigorous IV hydration and pain relief, what else should be done for presentation for ascending cholangitis or biliary
obstruction?
ERCP within 24 hours of presentation for ascending cholangitis or biliary
obstruction
For pancreatitis, what time frame is fluids beneficial?
Fluid resuscitation (250-500 mL/h) is most beneficial in the first 12-24 hours and
may be detrimental after this therapeutic window.
When do Pancreatic pseudocysts require drainage ?
Pancreatic pseudocysts do not require drainage unless they cause significant
symptoms or are infected, regardless of size.
What is an important step in evaluation of patients with pancreatic necrosis?
surgical consultation for pancreatic necrosis
Which clinical syndrome is associated with jaundice, leukocytosis, and tender hepatomegaly, with or without fever, AST and ALT measurements <300 to 500 U/L, with an AST/ALT ratio >2.0?
Severe alcoholic steatohepatitis is called alcoholic hepatitis and is symptomatic.
When is Prednisolone indicated for
patients Alcoholic Hepatitis?
Prednisolone is indicated for
patients with a Maddrey Discriminant Function (MDF) score ≥32, Model for End-Stage
Liver Disease (MELD) score >20, or encephalopathy.
For alcoholic hepatitis, when should prednisolone should be discontinued for non improvement?
If the bilirubin level (or Lille score) does not improve by day 7, prednisolone should be
discontinued.
Should you use glucocorticoids in patients with alcoholic hepatitis ?
Do not use glucocorticoids in patients with alcoholic hepatitis and GI bleeding,
infection, pancreatitis, or kidney disease.
Which clinical syndrome is associated with elevation of aminotransferase levels, elevated IgG levels, positive ANA and anti–smooth muscle antibody titers, positive p-ANCA or anti-LKM I antibody?
Autoimmune Hepatitis
How is Autoimmune Hepatitis diagnosed?
Liver biopsy establishes the diagnosis.
What other conditions can be found in patients with autoimmune hepatitis?
Fifty percent of patients with autoimmune hepatitis have other autoimmune diseases,
such as thyroiditis, ulcerative colitis, or synovitis.
Which clinical syndrome is associated with High serum total protein and low serum albumin levels?
High serum total protein and low serum albumin levels suggest an elevated
serum γ-globulin level, which may be the only clue to hypergammaglobulinemia.
When should patients with autoimmune hepatitis be considered for treatment with glucocorticoids or Azathioprine?
Patients who have active inflammation on liver biopsy specimens or are symptomatic
should be considered for treatment with glucocorticoids and azathioprine. Relapse
What is the treatment for autoimmune hepatitis ?
autoimmune hepatitis be considered for treatment with glucocorticoids or Azathioprine?
Which clinical syndrome is associated with a narrowed main pancreatic duct or parenchymal
swelling (“sausage-shaped” pancreas) ?
Autoimmune Pancreatitis
In a patient with Autoimmune Pancreatitis, what other clinical condition should be excluded?
It is important to exclude pancreatic cancer; biopsy may be necessary.
Which type (type 1 autoimmune pancreatitis or type 2 AIP) is more likely seen with elevated IgG4-related diseases and other other IgG4-related
diseases, such as Sjögren syndrome, PSC, bile duct strictures?
Type 1 AIP is seen in older men and may be associated with other IgG4-related
diseases, such as Sjögren syndrome, PSC, bile duct strictures, autoimmune thyroiditis,
retroperitoneal fibrosis, sclerosing sialoadenitis, and interstitial nephritis. Serum IgG4
level is increased.
Which type (type 1 autoimmune pancreatitis or type 2 AIP) is more likely associated with chronic pancreatitis and IBD and is less likely to include
elevated IgG4 levels?
Type 2 AIP is associated with chronic pancreatitis and IBD and is less likely to include
elevated IgG4 levels.
What is the treatment for both type 1 and 2 Autoimmune Pancreatitis?
Most patients with type 1 or 2 AIP respond to glucocorticoids. Patients with relapsed
disease typically respond to glucocorticoid retreatment.
What age, demographic and comorbidity require screening for barretts esophagus?
Screen men aged >50 years with GERD symptoms for more than 5 years and additional risk factors (nocturnal reflux symptoms, hiatal hernia, elevated BMI, tobacco use, intra-abdominal distribution of fat) to detect BE.
How is Barretts esophagus diagnosed?
The diagnosis of BE is based on endoscopic tissue biopsy.
What is the Treatment for patients with BE without dysplasia?
Treat patients with BE without dysplasia with a PPI.
what is the treatment for patients with barretts with confirmed low- or high-grade dysplasia?
Endoscopic ablation or mucosal resection is recommended for patients with confirmed
low- or high-grade dysplasia.
In patients with BE and no dysplasia, how often should surveillance examinations occur?
In patients with BE and no dysplasia, surveillance examinations should occur at intervals
no more frequently than 3 to 5 years.
For patients with Barrets E and low-grade
dysplasia who do not choose endoscopic ablation, how often should surveillance examinations occur? .
More frequent intervals of 12 months are indicated in patients with BE and low-grade
dysplasia who do not choose endoscopic ablation.
Do Women with GERD require routine screening for Barretts?
Women with GERD do not require routine screening for BE.
Should you select antireflux surgery to prevent the progression of BE to
adenocarcinoma?
Do not select antireflux surgery to prevent the progression of BE to
adenocarcinoma.
Which clinical syndrome occurs secondary to ingestion of wheat gluten or related rye and barley
proteins in genetically predisposed persons?
Celiac Disease
what other autoimmune conditions are associated with celiac disease?
type 1 diabetes mellitus
* autoimmune thyroid disease
which cancer is associated with celiac disease?
small bowel lymphoma
How is celiac disease diagnosed?
Diagnostic tests include an IgA anti-tTG antibody assay with small bowel biopsy for
those with a positive antibody assay.
In testing for celiac disease, what is the next step diagnostic tests after someone has a positive IgA anti-tTG antibody assay?
small bowel biopsy
In testing for celiac disease, what is the next step diagnostic tests after someone has a positive IgA anti-tTG antibody assay?
small bowel biopsy
For patients with suspected celiac disease, and IgA
deficiency what additional step should be considered to make a diagnosis of celiac disease?
An association between celiac disease and IgA
deficiency may lead to false-negative IgA-based tests. In patients with IgA deficiency,
assays for IgG anti-tTG or IgG-deamidated gliadin peptides are necessary.
what should be measured in all patients with newly diagnosed celiac disease?
Measure bone mineral density in all patients with newly diagnosed celiac disease.
How can the effectiveness of diet therapy for celiac be determined?
by remeasuring IgA anti-tTG antibody
titers or repeating small bowel biopsies.
what is the most common reason for failure of a gluten-free diet?
Nonadherence is the most common reason for failure of a gluten-free diet.
for celiac patients who are adherent to gluten free diet, and have recurrent malabsorption, what should they be evaluated for next?
Adherent
patients with recurrent malabsorption should be evaluated for other conditions,
including microscopic colitis and intestinal lymphoma.
Which med may be added initially to hasten dermatitis herpetiformis associated wit celiac?
Dapsone may be added initially to hasten dermatitis herpetiformis symptom resolution.
.
before using Dapsone what should you check for?
Dapsone may be added initially to hasten dermatitis herpetiformis symptom resolution.
Before using dapsone, check for G6PD deficiency.
when treating constipation, after Increasing physical activity and dietary fiber, what is the first step in treatment?
Add soluble fibers, such as psyllium and methylcellulose.
Which clinical syndrome is associated with this pic?
Melanosis coli
Which clinical syndrome is associated with this pic?
Esophageal Candida
Which clinical syndrome is associated with this pic?
Leukocytoclastic Vasculitis, Leukocytoclastic vasculitis consistent with HCV-associated mixed cryoglobulinemia
manifesting as palpable purpura.
Which clinical syndrome is associated with this pic?
Pyoderma Gangrenosum:
Which clinical syndrome is associated with this pic?
Colonic Ischemia
Which clinical syndrome is associated with this pic?
Primary Sclerosing Cholangitis
