GI Flashcards
1
Q
What are three measures of malnutrition that correlate with wound healing?
A
- BMI <18.5
- > =15% body weight loss in 3 months
- Albumin <3 (<2.2 predicts wound healing failure)
2
Q
How is hepatic encephalopathy medically managed?
A
Rifaxmin
Lactulose
Zinc
3
Q
When is percutaneous cholecystostomy done?
A
When patients don’t want laparoscopic cholecystectomy
4
Q
Ogilvie’s syndrome affects which segments of large bowel?
A
Ascending and transverse (up to the splenic flexure)
Descending is normal
5
Q
Acute colonic pseudo-obstruction (Ogilvie’s syndrome) - treatment
A
Conservative: Ambulation, IV fluids, electrolyte repletion
Next: CT with contrast if does not resolve
After: Neostigmine (adverse: bradycardia)
After that: Colonoscopy without insufflation of air to suck out air, followed by rectal tube, then eventually hemicolectomy
6
Q
How can small and large bowel be differentiated on abdominal X-ray?
A
Small bowel: plicae circularis/mucosal infoldings that span the bowel width; multiple loops; central location
Large bowel: Absence of mucosal infoldings; haustra (that may be absent if severely distended)
7
Q
Large bowel distention is typically where and caused by what?
A
Sigmoid colon, resulting in coffee bean shape
Caused by colon cancer in US, sigmoid volvulus elsewhere
8
Q
Pigmented stones:
Green
Black
Brown
A
Green - cholesterol
Black - unconjugated bilirubin (typically from hemolysis)
Brown - infection (bacterial beta-glucuronidase deconjugates bilirubin; smooth and not jagged; form in common bile duct, not GB)
9
Q
When is a HIDA scan used for diagnosis of gallstone pathology?
A
Acute cholecystitis where US was equivocal
10
Q
How is ascending cholangitis managed differently than choledocholithiasis?
A
Skip to ERCP, bypassing MRCP
Also blood culture, IV antibiotics, IV fluids
11
Q
How are biliary dyskinesia and acute cholecystitis diagnosed differently?
A
HIDA scan:
Acute cholecystitis - failure of dye to get into GB
Biliary dyskinesia - failure of dye to empty
12
Q
How to tell whether a stone has passed the common bile duct?
A
Admission and serial labs or MRCP - a stone that has not passed should then be removed using ERCP
13
Q
What antibiotics would you use for acute cholecystitis or ascending cholangitis?
A
Ampicillin-sulbactam and metronidazole
14
Q
What is suggested by a THIN-walled, distended gallbladder?
A
Malignancy that is causing obstruction
15
Q
Is primary biliary cholangitis intrahepatic and/or extrahepatic? More common in women or men?
A
Intrahepatic only; women mostly (30s-60s)
16
Q
Why is incidence of hepatocellular carcinoma greatest in Asia?
A
Incidence of HBV/HCV, often resulting in maternal-fetal transmission
Other risk factors include aflatoxin and betel nut chewing, heavy alcohol use
17
Q
What tumor markers are associated with cholangiocarcinoma?
A
CA 19-9 and CEA
18
Q
Sialadenosis - etiology and pathogenesis
A
Benign, noninflammatory disease, without fluctuation and not associated with eating:
Overaccumulation of secretory granules in acinar cells - chronic alcohol use, bulimia, malnutrition
Fatty infiltration - diabetes, liver disease
19
Q
Sialadenosis - differential diagnoses
A
Sialolithiasis - fluctant, painful, worse with eating
Parotitis - associated with mumps
Pleomorphic adenoma - unilateral
Sjogren - bilateral due to lymphocytic infiltration, but would have dry mouth as well
20
Q
Colon cancer surveillance post-resection
A
1 year after, then every 3-5 years
Stages II/III: add periodic CEA testing and annual CT
21
Q
What is the purpose of 5% or 25% albumin?
A
Volume expansion or to prevent rebound/shock after large-volume paracentesis
22
Q
Crepitus in abdominal wall adjacent to gallbladder suggests what?
A
Emphysematous cholecystitis - gas in gallbladder wall, air-fluid levels in gallbladder - due to bacteria (e.g. Clostridium, some E. coli)
Risk factors - diabetes, immunosuppression, vascular compromise
23
Q
Biliary-enteric fistula shows what signs depending on part of intestine?
A
Small intestine: asymptomatic but may cause gallstone ileus - intermittent bowel obstruction (nausea, diffuse abdominal pain) over days as gallstone passes
Large intestine: bile acid diarrhea
24
Q
Hepatic adenoma - risk factors, sequelae, treatment
A
Risk: Women on long-term OCPs; pregnancy; anabolic androgen use
Sequelae: Hemorrhage, malignant transformation
Treatment: Surgery better than biopsy due to risk of bleeding
25
What is focal nodular hyperplasia of liver?
Common mass lesion in young women caused by hyperperfusion from anomalous arteries
Not associated with OCPs
26
What is the most common benign liver lesion?
Hepatic hemangioma
27
Hepatic hemangioma on CT
Centripetal enhancement - moving from periphery to center
28
Which liver mass has arterial flow (hyperdense with contrast) and central scar on imaging?
Focal nodular hyperplasia
29
What numbers are useful in diagnostic paracentesis?
Serum-to-ascites albumin gradient (SAAG) >=1.1 in portal hypertension
Protein <2.5 consistent with cirrhosis (>= 2.5 suggests right-sided heart failure)
Cell count/diff: lymphocytic predominance - malignancy, tuberculosis; neutrophil predominance (>=250) - spontaneous bacterial peritonitis
Bilirubin - biliary or bowel perforation (brown fluid, severe abdominal pain with peritoneal signs
Malignancy - low glucose, SAAG <1.1, bloody ascites
30
Esophageal perforation signs, treatment
1. Severe chest pain
2. Back pain
3. Systemic findings (e.g. fever) without hours
4. Minority: crepitus on palpation or crunching on auscultation (Hamman sign)
Dx: Water-soluble contrast esophagography or CT; barium swallow if inconclusive
Treatment: Surgery, IV antibiotics, PPI
31
How do fat and protein stimulate gallbladder contraction?
Passing through SI --> I cell releases CCK --> gallbladder contracts
32
Copper deficiency symptoms
Neurologic dysfunction (ataxia, peripheral neuropathy - similar to B12 deficiency)
Anemia
Hair fragility
Skin depigmentation
Hepatosplenomegaly
Edema
Osteoporosis
33
Selenium deficiency symptoms
Cardiomyopathy
Thyroid dysfunction
Immune dysfunction
34
Zinc deficiency symptoms
Alopecia
Pustular rash (perioral, extremities)
Hypogonadism
Impaired wound healing
Impaired taste
Immune dysfunction
35
How can cholecystectomy lead to diarrhea? Treatment?
Unabsorbed bile acids cause mucosal irritation by entering terminal ileum too rapidly and overwhelming resorptive capacity
Can also happen with ileal disease that impairs bile absorption (e.g. Crohn, radiation)
Tx: Bile acid-binding resins (e.g. cholestyramine, colestipol)
36
Microscopic colitis - epi, cause, treatment
Women
Triggered by meds (e.g. PPI, NSAIDs)
Treat with budesonide
37
Roux-en-Y gastric bypass - complication and treatment
Complication: stomal (anastomotic) stenosis
Treatment: EGD visualization and balloon dilation; surgery if failed
38
What causes exacerbation of Gilbert syndrome?
Stressors:
Febrile illness
Fasting
Vigorous exercise
Surgery
39
Describe the watershed lines of the colon that are at highest risk of ischemic colitis
Splenic flexure - watershed between superior and inferior mesenteric arteries
Rectosignmoid junction - watershed between sigmoid artery and superior rectal artery
40
Ischemic colitis - appearance on endoscopy
Pale mucosa with petechial bleeding
Bluish hemorrhagic nodules
Cyanotic mucosa with hemorrhage
41
Mallory-Weiss tear - risk factors, dx, treatment
Risk:
Alcohol use disorder
Hiatal hernia
Dx: Endoscopy
Tx: Endoscopic electrocoagulation or local injection of epinephrine
42
Abdominal compartment syndrome - causes, measurement?
Causes - massive fluid resuscitation coupled with trauma, burns (systemic inflammation, capillary permeability, third spacing)
Management - NG tube to decrease intraabdominal volume, sedation to increase abdominal wall compliance, surgical decompression (definitive)
43
44
Infliximab
TNF-a receptor antagonist for Crohn
45
Adalimumab
TNF-a antagonist for Crohn
46
Toxic megacolon can complicate which conditions?
1. Ulcerative colitis
2. C diff
47
Describe biliary colic
Constant (not colicky/intermittent) epigastric or RUQ pain that radiates to upper back or right shoulder; occurs with cholelithiasis
Acute cholecystitis lasts longer than 6 hours
48
Gastroparesis symptoms
1. Bloating
2. Early satiety
3. Postprandial emesis
4. Food aversion
5. Weight loss
Can occur via vagal nerve injury after Nissen fundoplication
49
Explain enteric hyperoxaluria
Fat malabsorption due to decreased bile acid uptake (from Crohn, gastric bypass, etc.) --> fat complexes with calcium --> less calcium to bind to oxalate --> increased enteric oxalate absorption --> Ca oxalate stones
50
Iliocecal resection increases risk of what?
Small intestinal bacterial overgrowth - no ileocecal valve allows colonic bacteria to enter SI
51
SI bacterial overgrowth - diagnosis
Carbohydrate breath test (lactulose, glucose --> fermented --> hydrogen and methane)
Periodic measurement - early rise in breath hydrogen (<1.5h vs 2-3h) suggests small bowel fermentation
Gold standard: jejunal aspirate with intestinal fluid culture
52
Fecal elastase test
Sensitive/specific indirect test for pancreatic function - low in chronic pancreatitis
53
Hepatic angiosarcoma - epi
Older men exposed to toxins (e.g. vinyl chloride gas, inorganic arsenic compounds, thorium dioxide)
54
Which distal LN can abdominal cancers typically spread to?
Thoracic duct to left supraclavicular LN (Virchow node)
55
Ursodeoxycholic acid - indications
1. Cholesterol gallstones
2. PBC or PSC - slow disease progression
56
How would abscess appear on CT?
Hypodense, round, well-defined, with surrounding abscess membrane
57
Explain the different kinds of esophageal dysphagia
Feels like food stuck in throat (as opposed to oropharyngeal dysphagia with difficulty swallowing or choking)
If solid and liquid, motility disorder; intermittent is esophageal spasm while progressive is achalasia
Solids is mechanical obstruction; solids to also liquids is developing stricture or cancer
58
Eosinophilic esophagitis - appearance and treatment
Furrowing, small whitish exudates, multiple stacked ring-like indentations (trachealization)
Treatment:
1. Dietary
2. PPI
3. Topical glucocorticoids (swallowed fluticasone spray, budesonide)
59
Colovesical fistula - etiologies, imaging
Diverticular disease, Crohn, colorectal malignancy
CT with oral or rectal contrast, followed by colonoscopy to rule out malignancy
60
Sphincter of Oddi dysfunction - signs, concerns, dx, treatment
Feels like biliary colic but after cholecystectomy
Opioids can increase sphincter contraction and precipitate pain
Manometry for diagnosis, sphincterotomy for treatment
61
Colon cancer - when surgery, when chemo and/or radiation?
Surgery for limited metastasis
Chemo for unresectable cases
Combined chemo and radiation for nonoperable rectal adenocarcinoma and anal SCC
Note: Radiation avoided in tumors proximal to rectum because adverse effects (e.g. radiation enteritis) can be severe
62
Contained appendiceal abscess should be managed how?
Antibiotics, bowel rest, possibly percutaneous drainage
Interval appendectomy in 6-8 weeks
This is due to very high complication rate if surgery is done immediately
63
What is primary sclerosing cholangitis associated with?
Underlying ulcerative colitis (90%)
High risk of cholangiocarcinoma
64
Cholangiocarinoma risk is greatest in whom?
Fibropolycystic liver disease
Primary sclerosing cholangitis
65
How does IBD cause toxic megacolon?
Inflammatory mediator-induced increase in NO production --> smooth muscle dilation
Extension of mucosal inflammation into smooth muscle layer --> muscle paralysis and dilation
66
When is diagnostic peritoneal lavage used?
If hemodynamically unstable, no peritonitis and no/inconclusive free fluid on FAST, and too unstable for CT
67
Air in intrahepatic bile ducts
1. Emphysematous cholecystitis
2. Cholecystoenteric fistula (can lead to gallstone ileus)
68
Why is gallstone ileus a misnomer?
It is not a functional disruption of motility, but rather a mechanic bowel obstruction
69
Cecal or sigmoid volvulus in younger patients?
Cecal - often report prior self-resolving episodes because many have congenital mobile cecum (i.e. mesentery failed to fuse with parietal peritoneum)
70
Cecal or sigmoid volvulus - which one endoscopic detorsion vs surgery?
Sigmoid volvulus endoscopic detorsion first-line - much higher success rate
71
Mandibular tori
Benign bony growths (exostoses) that protrude from mandible
More common than palatal tori - midline, symmetric, bony lesions on hard palate
72
When to drain diverticular abscess?
>=4 cm; place under CT or ultrasound guidance
73
When are peripheral mu-opioid receptor antagonists used for opioid-induced constipation?
Those who have failed conventional laxatives
Ex. Methylnaltrexone, naloxegol, naldemedine
74
Most cases of vitamin K deficiency develop in whom?
Disorders of pancrease/biliary system (vitamin K is fat-soluble)
Prolonged courses of antibiotics
75
Proximal vs mid/distal SBO
Proximal: Early vomiting, abdominal discomfort, abnormal contrast filling on x-ray
Mid/Distal: Delayed vomiting, colicky abdominal pain, prominent distension, constipation-obstipation, hyperactive bowel sounds, dilated bowel loops on x-ray
76
Name the retroperitoneal GI structures
Latter duodenum, ascending and descending colon, pancreas head/body - these are all secondarily retroperitoneal
Esophagus, rectum - primarily retroperitoneal
77
IBS treatment
Loperamide + low FODMAP diet:
Fermentable Oligosaccharides, Disaccharides, Monosaccharides, And Polyols
78
Tumor proximal vs distal to anal dentate line - which draining LN?
Proximal: internal iliac, inferior mesenteric LN
Distal: inguinal LN
79
What lab particularly predicts pancreatitis mortality?
BUN
80
What is stool elastase a marker for?
Pancreatic exocrine function - low levels suggestive of chronic pancreatitis
81
Diffuse esophageal spasm medical treatment
CCB (eg diltiazem)
82
Primary billiary cholingitis treatment
Ursodeoxycholic acid:
More hydrophilic and prevents Injury from endogenous bile acids
Increases billiary secretion
Immunomodulatory effects
83
What is S gallolyticus infective endocarditis associated with?
Colorectal cancer, IBD
Perform colonoscopy, LFTs, hepatitis serology
84
MALT tumors are associated overwhelmingly with what?
H. pylori - treat with quadruple therapy
If negative, treat with radiotherapy, immunotherapy (eg rituximab), or single-agent chemo
85
Pernicious anemia is related to risk of what GI cancers?
Gastric adenocarcinoma
Gastric carcinoid
86
Spontaneous bacterial peritonitis - diagnosis
PMN >=250 in ascitic fluid
Supported by SAAG >=1.1, protein <1
87
Primary biliary cholangitis - comorbidities
1. Fat-soluble vitamin deficiency
2. Osteoporosis as a result of vitamin D deficiency
3. Hepatocellular carcinoma
Not CRC, that is PSC and UC, which are associated with each other
Not ascending cholangitis - that is PSC
88
Primary biliary cholangitis - treatment
Ursodeoxycholic acid
89
Most common inciting factors of hepatorenal syndrome
GI bleeding
SBP
90
Hepatorenal syndrome - temporizing treatment
Splanchnic vasoconstrictors - midodrine, terlipressin, or norepinephrine + octreotide, as well as albumin
91
What medications cause esophagitis?
Tetracyclines (acid effect)
Bisphosphonates
Potassium chloride (osmotic injury), iron
Aspirin/NSAIDs (disruption of protective layer)
92
Treatment for triglyceride induced pancreatitis
Triglycerides >1,000
Insulin therapy or apheresis
93
Patients with upper but not lower GI bleed have what lab result?
Elevated BUN and BUN/Cr ratio
Potentially due to increased urea production from intestinal breakdown of Hgb, as well as hypovolemia
94
Vitamin B12 deficiency is rare in alcoholics except for those who also have...
Chronic pancreatitis
95
What liver issue can cause splenic platelet trapping with thrombocytopenia and hepatosplenomegaly?
Cirrhosis
96
Alcoholic liver disease would have what else elevated?
GGT, ferritin
97
Boerhaave pleural effusion is most likely on what side?
Left - due to intrinsic weakness of left posterolateral aspect of distal intrathoracic esophagus
98
How can cirrhosis affect a male specifically?
Hypogonadism - due to primary gonadal injury or hypothalamic-pituitary axis dysfunction
Also elevated estradiol due to increased conversion from androgens
99
Inflammatory diarrhea vs regular diarrhea
Inflammatory has leukocytosis and reactive thrombocytosis
Caused by IBD, infection, ischemic colitis (e.g. sudden hypotension), radiation colitis (e.g. prostate cancer treatment)
Intestinal wall injury causes systemic inflammatory response as well as bleeding into stool
100
Medications that cause intraphepatic cholestasis
Certain antibiotics (e.g. macrolides)
Anabolic steroids
Oral contraceptives
100
Clues to eosinophilic esophagitis
Heartburn that doesn't respond to standard GERD meds
Manometry showing esophageal hypercontractility
101
102
Do prokinetic agents help prevent aspiration pneumonia?
No - use thickened liquids in chin-down position and bed elevation to 30-45 degrees
103
Differentiate SAAG between ascites and HF/venoocclusive/pericardial disease
SAAG >=1.1 for all, but ascites protein <2.5 in cirrhosis and >=2.5 in others
104
SBP ascites
PMN >=250
SAAG >=1.1
Protein <1
105
Green/black stools ico poisoning
Acute iron poisoning - color caused by disintegrating iron tablets
106
Proctalgia fugax
Recurrent, brief episodes of rectal pain unrelated to defecation
Functional pathology
Treat with reassurance
Refractory: Nitroglycerin cream +/- biofeedback therapy
107
Signs of diarrhea due to laxative abuse
Dark brown proximal colon
Metabolic alkalosis, rather than predicted acidosis
Profound hypokalemia prevents chloride reabsorption, preventing exchange with bicarb and resulting in retained bicarb
108
Tea-colored stools
VIPoma
109
When does hemochromatosis present in women?
After menopause - menstruation slows iron accumulation
110
What is jejunal aspiration used for?
SIBO diagnosis
111
What are examples of pseudodiverticula?
Mucosa and submucosa but no muscle, due to intraluminal pressure rather than external traction:
1. Zenker
2. Diverticulosis
Contrast with true diverticula:
1. Meckel
2. Appendix
112
Esophageal webs are associated with...
Plummer-Vinson syndrome:
Iron deficiency anemia
Glossitis
113
Diffuse esophageal spasm - treatment
CCBs
TCAs
Nitrates
114
Who should undergo endoscopy for dysphagia?
All >60 yo
Red flags if <60 yo
115
Type A (fundal) vs Type B (antral) chronic gastritis
Type A: autoantibodies to parietal cells, pernicious anemia; increased risk of adenocarcinoma and carcinoid
Type B: NSAIDs or H pylori; increased risk of PUD and gastric cancer
116
H pylori urea breath or stool antigen test - which is more sensitive?
Stool
117
MALT lymphoma is associated with...
Chronic H pylori
Treat with triple therapy
118
Zollinger-Ellison causes what electrolyte imbalance?
Hypercalcemia from hyperPTH
119
Which diabetes drugs can worsen gastroparesis?
Pramlintide
GLP-1 agonists
120
PAS+ stain granules in lamina propria, arthritis, LAD, carsiac issues
Whipple disease
121
Carcinoid syndrome can result in what vitamin deficiency?
Niacin/B3 (4 Ds) - tryptophan needed for both niacin and serotonin
122
IBS-C vs IBS-D treatment
IBS-C:
Cl channel activators (lubiprostone)
Guanylate cyclase activators (linaclotide, plecanatide)
IBS-D:
Rifaximin
Both: TCA or SNRIs
123
Colon cancer screening guidelines for other scenarios
IBD: every 1-2 years starting 8-10 years after diagnosis
Lynch: every 1-2 years starting at 25 yo or 5 years prior to first family diagnosis
FAP: sigmoidoscopy every year starting at 12 yo
High-risk colonoscopy findings: every 3-5 years
124
Gardner syndrome
FAP + osteomas (skull, facial bones) + fibromatosis
Hypertrophy of retinal pigment epithelium
125
FAP + brain tumors (neurologic signs)
Turcot syndrome
126
Acute vs chronic radiation proctitis
Acute: within 3 mo; diarrhea, mucus, minimal bleeding; antidiarrheals and butyrate enema
Chronoc: 3 mo - 2 yr; constipation, rectal pain, severe bleeding; sucralfate or steroid enemas, endoscopic thermal coagulation for bleeding
127
Ulcerative colitis 5-ASA agents used (not in Crohn)
Sulfasalazine, mesalamine
128
Hep B - markers of carrier vs transmissibility
Persistent surface Ag: carrier
Persistent e Ag: high transmissibility
129
Best test of acute HAV
IgM HAVAb
130
Valproic acid overdose hepatitis - treatment
L-carnitine
131
Nephrotic syndrome ascites
SAAG <1.1 (conditions not related to portal HTN)
Albumin <2.5 (as is cirrhosis)
132
SBP prophylaxis
Bactrim or fluoroquinolone - can give for cirrhotic patient admitted for GI bleed/variceal hemorrhage
133
Hepatorenal syndrome - treatment
Octreotide (splanchnic vasodilation)
Midodrine (increase BP)
May require dialysis
134
Which clotting factor is not low in cirrhosis?
Factor 8
135
NASH management
Vitamin E
Pioglitazone
136
Wilson disease - treatment
Penicillamine or trientine (copper chelators)
Zinc (increases fecal excretion)
Dietary restriction
137
Focal nodular hyperplasia vs hepatic hemangioma vs hepatic adenoma
FNH: central stellate scar with portal phase washout
Hepatic hemangioma: heterogenous portal phase washout; 2x surveillance needed if lesion >5 mm, stop if growth <3 mm/year
Hepatic adenoma: associated with OCP, risk of intraperitoneal hemorrhage; 6-month surveillance if lesion <5 cm followed by annual MRI, surgery if >5 cm or symptomatic
138
Scorpion sting can cause what GI issue?
Acute pancreatitis
139
Alternating stenosis and dilation of main pancreatic duct (chain of lakes)
Chronic pancreatitis
140
D cell tumor is...
Somatostatinoma - usually found in head of pancreas
Whipple procedure if not metastatic, octreotide to manage symptoms
