GI Flashcards
What gene is associated with FAP?
APC
What gene is associated with Lynch Syndrome?
MSH1/6; MLH1
What gene is associated with Peutz-Jegher?
STK1
What does acetaminophen toxicity do to liver?
1.depletes intrahepatic glutathione
2. overaccumulation of NAPQI leads to mitochondrial damage (oxidative hepatocellular injury)
Adverse effect of PPIs
1.malabsorb Fe,Ca,Mg, B12, 2)risk of infection 3)osteoporosis, CKD, IBD 4)small bowel bacterial overgrowth
What are the labs of Cholangiocarcinoma (ALP, BIL) and what will you see on imaging? histological presentation?
ALP up, BIL up; bile duct dilation but no stone; adenocarcinoma with cuboidal/columnar cells, prominent nucleoli arranged in glandular structure; mucin and desmoplastic
G cells
D cellls
I cells
S cells
K cells
M cells
Gastrin, up H+
Somatostatin down GI secretions
Cholecystikinin pancreaticenzyme,bile HCO3up
Secretin HCO3 up, H down
GIP up insulin down H
Motilin up GI motility
What are the risk factors for hepatic angiosarcoma?
PVCs, vinyl chloride (CD31 marker)
If a pt needs diphenoxylate (opioid antidiarrheal), which conjugate medicine could be given to discourage opioid abuse?
atropine (causes adverse reactions if opoiod taken in large amounts)
After GI tract infection, could become lactose intolerant, what would happen to pH of stool, hydrogen breath test, and stool osm?
pH stool down; H+ breath up; stool osm up
Which gene is involved in hereditary pancreatitis?
trypsinogen or SPINK1 (serinpeptidase inhibitor Kazal type 1) which is a trypsinogen inhibitory
Which med for post chemo nausea and vomiting that is neurokinin 1 antagonist
Aprepitant
If there is a mutation in KIT receptor tyrosine kinase gene and there is syncope, flushing, hypotension, pruritus, vomiting, diarrhea, up gastrin which syndrome is this?
Systemic mastocytosis
3 drugs for Hep C tx
RNA dependent RNA polymerase inhibitor (sofosbuvir)
Protease inhibitors (after host makes proteins must cleave proteins with protease)–Simeprevir
NS5A inhibitor ledispravir (not sure MOA)
Retroperitoneal organs
SAD PUCKER
Suprarenal
Aorta and IVC
Duodenum (first part)
Pancreas (head and body)
Ureters
Colon (ascending colon)
Kidneys
Esophagus
Rectum (mid distal)
Small solitary pale nodules comprised of cords or normal appearing hepatocytes and central stellate scars, fibrous setae that surround abnormally large hepatic artery branch
focal nodular hyperplasia
osmotic laxative
lactulose, MgOH, polethylene glycol
peripheral mu opioid antagonist (for GI motility)
methylnaltrexone
fast acting laxative
bisacodyl, senna (abd. cramp, electrolyte disturbance)
What is the main HLA problem that cause celiac disease?
HLA DQ2/DQ8
treatment for DES (diffuse esophageal spasm) and nutcracker esophagus
TCA, sildenafil, nitrates (like Prinzmetal); PPI if needed
most accurate test for DES/nutcracker esophageal spasm
manometry
multiple concentric rings on endoscopy
esophageal esophagitis
TX: for esophageal esophagitis
eliminate allergenic foods; PPI; swallow steroid inhaler
pills that cause esophagitis
doxycycline, bisphosphonates (alendronate); KCl tablets
HIV CD4 count less than 100 with dysphagia, next management?
fluconazole + HIV therapy; if doesn’t work do endoscopy: Large ulcer CMV give gancyclovir; small ulcers HSV give acyclovir
Which esophageal problem is associated with iron deficiency anemia and could (rare) transform into squamous cell carcinoma?
Plummer-Vinson syndrome
TX Plummer Vinson
iron replacement
TX Schatzi ring
pneumatic dilation
TX Zenker’s diverticulum
surgery
diagnosis for achalasia, spasm and scleroderma
manometry
TX for Mallory Weiss severe or persistent bleeding
epinephrine injections or electrocautery
differential for RUQ pain
cholecystitis, biliary colic, cholangitis, perforated duodenal ulcer
differential for LUQ pain
splenic rupture; splenic flexture syndrome (IBD)
differential for RLQ pain
appendicitis, ovarian torsion, ectopic pregnancy, cecal diverticulitis
differential for LLQ pain
sigmoid volvulus, sigmoid diverticulitis, ovarian torsion, ectopic pregnancy
differential for mid epigastric pain
pancreatitis, aortic dissection, PUD
What test if you suspect Barrett’s?
endoscopy and biopsy
Barrett’s metaplasia (mild)
PPI and rescope 3-5 yrs
low grade dysplasia (Barrett’s)
PPI and rescope 6-12 months
high grade dysplasia
endoscopy with ablation, radiofrequency ablation or resection of mucosal
definitive test for gastritis
endoscopy + H pylori testing
Which neoplasm gives positive result for H pylori stool antigen?
MALToma
MCC of peptic ulcer
H. Pylori #2NSAIDs
meds for H. Pylori
clarithromycin + amoxicillin; if allergic to penicillin then clarithromycin + metronidazole (other meds can try if not effective tetracycline: ONLY USE FOR TETRACYCLINE be careful not pregnant/nursing/ see contraindicationis)
after H Pylori treatment
30-60 days post treatment; retest
Who gets stress ulcer prophylaxis?
head trauma pts; burn pts; intubated pts; pts with sepsis and coagulopathy
Do you treat asymptomatic H pylori?
NO
recurrent ulcers despite treatment?
inject secretin and see if gastrin levels go down; if go down (normal); if not, think gastrinoma
tx for gastrinoma if localized?
surgery
tx for gastrinoma if metastasized?
PPI for life
diabetic gastroparesis tx:
erythromycin or metaclopramide (cannot be used permanently causes dystonia and hyperprolactinemia)
best initial test for diabetic gastroparesis
upper endoscopy or abdominal CT to exclude luminal gastric mass or abdominal mass
most accurate test for diabetic gastroparesis
food bolus tagged with technetium
upper GI bleeding differential
esophagitis, gastritis, cancer, duodenitis, varices
lower GI bleeding differential
angiodysplasia, polyps, IBD, cancer, upper GI bleeding, hemorrhoids, fissures
Acute GI bleeding next best step of management
replace fluids, check Hemocrit, PLT and coag tests ; replace fluids most important than etiology
Tx for GI bleeding
1-fluid replacement
#2-packed RBC if hemocrit less than 30, esp. if pt is older or has CAD; younger pts sometimes can tolerate HCT 20-25
#3 FFP if PT or INR elevated and actively bleeding
#4 PLTs if PLT less than 50,000 and bleeding
#5 reversal of anticoagulants if needed
Xa inhibitor reversed by andexanet alfa
dabigatran reversed by idarucizumab
warfarin reversed by prothrombin complex concentrate
#5 inject epinephrine to bleeding vessels (cauterization)
reversal of Xa inhibitor
andexanet alfa
dabigatran reversal
idarucizumab
warfarin reversal
Prothrombin complex concentrate (PCC)
tx for esophageal and gastric varices
octreatide; banding; TIPS; antibiotics if ascites is present to prevent SBP (spontaneous bacterial peritonitis)
best initial test for C. diff?
C diff toxin test
most accurate test for C diff?
PCR
Tx for C diff?
vancomycin if no response fidoximicin
monoclonal antibody against C diff?
bezlotuxumab
If all treatments fail for C diff?
fecal transplant
distinguish between chronic pancreatitis and celiac disease
celiac has iron deficiency
anti tissue transglutaminase can be falsely negative in what condition?
IgA deficiency
three tests for celiac disease:
anti-tissue transglutaminase,
antiendomysial antibody
IgA antigliadin antibody
most accurate test for celiac disease?
small bowel biopsy; essential to rule out LYMPHOMA
most accurate test for chronic pancreatitis:
secretin stimulation test: normal pancreas releases large volume of bicarb rich fluids
down fat absorption, fat vitamin deficiencies, arthralgias, ocular finding, dementia, seizure, fever, lymphadenopathy, which disease?
Whipple’s
Tx for Whipple’s
ceftrioxane first; then TMP/SMX
Tx chronic pancreatitis
replace enzymes
Tx celiac
gluten free diet
treatment for tropical sprue
TMP/SMX or doxycycline
treatment for tropical sprue
TMP/SMX or doxycycline
flushing, wheezing, diarrhea, right heart abnormalities
carcinoid syndrome
diagnosis for carcinoid syndrome
urine 5HIAA
Tx for carcinoid syndrome
octreatide to control diarrhea and symptoms
tx for diarrhea dominant IBS
rifaxamin or eluxadoline
tx for constipation dominant IBS
fiber, polyethylene glycole (PEG)
ALL IBD pts have?
ANEMIA
possible marker of UC
ANCA
possible marker for Crohn’s
anti saccharomyces cervisiae antibody (ASCA)
Tx for IBD
steroids (prednisone but best budesonide) for acute exacerbations; 5-ASA (mesalamine) for remission;
Tx for UC limited to rectum:
Asacol (mesalamine) or Rowasa
Tx for perianal Crohn’s
Pentasa (mesalamine) or ciprofloxacin+metronidazole
What mineral and vitamin for all IBD
Ca and Vita D
Tx for Crohn’s fistula?
anti-TNF (adalimumab, infliximab, etanercept) or anti IL 12/23 ustexinumab
Tx for short bowel syndrome
vita ADEK supplement; B12, Ca, Mg, Fe, Zn supplement; avoid high fat food; loperamide to slow bowel; teduglutide GLP agonist to slow bowel
Tx for SIBO (small intestinal bacterial overgrowth)
rifaximin
tx for microscopic colitis (chronic watery diarrhea)
steroids (budesonide, prednisone)
suspect diverticulitis DO NOT do what?
colonoscopy (might perforate); do CT scan
Tx diverticulitis
ciprofloxacin + metronidazole; or ceftriaxone + metronidazole; or amoxicillin/clavunate
MC complication of diverticulitis
abscess
Feed pts with acute diverticulitis?
NO all diverticulitis pts. NPO
routine colon cancer screening
start 50 y/o, every 10 yrs
previous adenomatous polyp how often should have colonoscopy?
every 3-5 years
previous Hx of colon cancer, how often should have colonoscopy?
1 year after resection; then 3 years; then 5 years
family hx of colon cancer, how often should have colonoscopy?
10 years before the family member’s age of discovery of colon cancer or 40 y/o whichever is younger; repeat every 5 years if family member was younger than 60
FAP, Gardner’s, Turcot (CNS involvement) and Juvenile polyposis how often need colonoscopy
start at 12 y/o; sigmoidoscopy every year, APC test
Peutz-Jegher pts how often need colonoscopy?
start at 8 y/o, every 3 years
stopping anticoags before colonoscopy? warfarin?
anticoags 1 day before and can resume one day after; warfarin 3-5 days before, can resume after
Which of the following associated with worse prognosis in pancreatitis? a) increased amylase b) increased lipase c) intensity of pain d) low Ca e) CRP increased
d) severe pancreatitis decreases lipase which = fat malabsorption; Ca usually binds with fat in bowel but if low fat absorption= low Ca absorption
Tx pancreatitis
NPO, IV fluids, analgesia, PPI (to decrease pancreatic stimulation to acid); CT/MRI if shows greater than 30% necrosis give antibiotic such as imipenem to decrease mortality; infected necrotic pancreas should be resected and surgically debrided to prevent ARDs and death
IGG4 related pancreatitis
autoimmune pancreatitis: may also have +ANA and +RF, recurrent jaundice, weight loss, abdominal pain in absence of alcohol or stones) biopsy to exclude cancer!
histology of autoimmune pancreatitis
lymphocytes and plasma cell infiltrates
Tx for autoimmune pancreatitis:
steroids
pancreatic cancer marker
Ca 19-9
pancreatic cancer labs
AMY/LIP normal: ALP, GGT, BIL up
When do you screen for liver cirrhosis with U/S
every 6 months
What should you perform if you discover new ascites?
paracentesis if abdominal tenderness and fever; check SAAG (serum ascites albumin gradient)
significance of SAAG
If SAAG less than 1.1 means infection; cancer; nephrotic syndrome
If SAAG more than 1.1 means CHF, portal HTN, hepatic vein thrombosis; or constrictive pericarditis
What prophylaxis do all variceal bleeding with ascites need?
SBP prophylaxis (cefotaxime or ceftriaxone); if have SBP need lifetime prophylaxis
Tx for encephalopathy
lactulose, rifaximin
Tx for ascites/edema
spirinolactone and other diuretics, paracentesis for large volume
Tx for varices
propranol and banding
tx for hepatorenal syndrome
somatostatin (octreatide) or midodrine
alcoholic hepatitis discriminating factor
4.6 * (pt’s PT-control PT) + BIL; if greater than 32 treat with steroids
woman 40, 50 y/o; fatigue/itching; normal BIL, increase ALP; xanthomas; osteoporosis
PBC primary biliary cholangitis
PBC main marker
anti-mitochondrial antibody
What med can decrease fibrosis in PBC
obeticholic acid
young male; IBD, pruritis, increase ALP, increase GTTp ; increase BIL
PSC primary sclerosing cholangitis
most accurate test for PSC
MRCP/ ERCP see beading
gene for hemochromatosis
HFE C282y gene mutation
signs of hemochromatosis
AST/ALT increased; fatigue/joint pain (pseudogout); erectile dysfunction in men, amenorrhea in women (clogged pituitary); skin darkening, DM, cardiomyopathy
which bacterial infections are pts with hemochromatosis more susceptible to and why?
Vibrio v., yersinia, Listeria because these organisms love Fe
Tx hemochromatosis
phlebotomy, Fe chaltor deferasirox/deferiprone
Before using these meds what should you check for: Anti CD 20 (rituximab, oftumumab); anti CD 52 alemtuzumab; HIV pre-exposure prophylaxis (PrEP) tenofovir and emtricitabine
Check for HEP B surface antigen
ACUTE HEP C only acute hep that is treated!
ALL ADULTS need to be tested for HEP C!
Tx chronic Hep C
sofosbuvir + ledipasvir or sofosbuvir + velpatasvir (choose this one if on test)
Interferon SE
arthralgia, myalgia, anemia, depression
ribavirin SE
anemia
Most accurate test for Wilson’s?
increased Cu urine excretion upon give penicillamine
Tx for Wilson’s?
Penicillamine and Zinc; if allergic to penicillin do not give Penicillamine; use zinc or trietine
NASH/NAFLD can be given which antioxidant
Vit E
possible TX for NASH
obeticholic acid
NASH and DM cotreatment
pioglitazone
MELD (Model for end stage liver disease) used to determine what?
who gets liver transplant first; up MELD score, faster transplant
benign liver disease “central stellate scarring”
focal nodular hyperplasia
Which benign liver disease changes with estrogen levels?
hepatic adenoma
