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Internal Medicine > GI > Flashcards

GI Flashcards

1
Q

What are three measures of malnutrition that correlate with wound healing?

A
  1. BMI <18.5
  2. > =15% body weight loss in 3 months
  3. Albumin <3 (<2.2 predicts wound healing failure)
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2
Q

How is hepatic encephalopathy medically managed?

A

Rifaxmin
Lactulose
Zinc

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3
Q

When is percutaneous cholecystostomy done?

A

When patients don’t want laparoscopic cholecystectomy

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4
Q

Ogilvie’s syndrome affects which segments of large bowel?

A

Ascending and transverse (up to the splenic flexure)

Descending is normal

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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

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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)

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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

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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)

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9
Q

When is a HIDA scan used for diagnosis of gallstone pathology?

A

Acute cholecystitis where US was equivocal

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10
Q

How is ascending cholangitis managed differently than choledocholithiasis?

A

Skip to ERCP, bypassing MRCP
Also blood culture, IV antibiotics, IV fluids

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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

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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

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13
Q

What antibiotics would you use for acute cholecystitis or ascending cholangitis?

A

Ampicillin-sulbactam and metronidazole

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14
Q

What is suggested by a THIN-walled, distended gallbladder?

A

Malignancy that is causing obstruction

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15
Q

Is primary biliary cholangitis intrahepatic and/or extrahepatic? More common in women or men?

A

Intrahepatic only; women mostly (30s-60s)

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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

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17
Q

What tumor markers are associated with cholangiocarcinoma?

A

CA 19-9 and CEA

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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

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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

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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

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21
Q

What is the purpose of 5% or 25% albumin?

A

Volume expansion or to prevent rebound/shock after large-volume paracentesis

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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

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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

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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

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25
Q

What is focal nodular hyperplasia of liver?

A

Common mass lesion in young women caused by hyperperfusion from anomalous arteries
Not associated with OCPs

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26
Q

What is the most common benign liver lesion?

A

Hepatic hemangioma

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27
Q

Hepatic hemangioma on CT

A

Centripetal enhancement - moving from periphery to center

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28
Q

Which liver mass has arterial flow (hyperdense with contrast) and central scar on imaging?

A

Focal nodular hyperplasia

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29
Q

What numbers are useful in diagnostic paracentesis?

A

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

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30
Q

Esophageal perforation signs, treatment

A
  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

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31
Q

How do fat and protein stimulate gallbladder contraction?

A

Passing through SI –> I cell releases CCK –> gallbladder contracts

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32
Q

Copper deficiency symptoms

A

Neurologic dysfunction (ataxia, peripheral neuropathy - similar to B12 deficiency)
Anemia
Hair fragility
Skin depigmentation
Hepatosplenomegaly
Edema
Osteoporosis

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33
Q

Selenium deficiency symptoms

A

Cardiomyopathy
Thyroid dysfunction
Immune dysfunction

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34
Q

Zinc deficiency symptoms

A

Alopecia
Pustular rash (perioral, extremities)
Hypogonadism
Impaired wound healing
Impaired taste
Immune dysfunction

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35
Q

How can cholecystectomy lead to diarrhea? Treatment?

A

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)

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36
Q

Microscopic colitis - epi, cause, treatment

A

Women
Triggered by meds (e.g. PPI, NSAIDs)
Treat with budesonide

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37
Q

Roux-en-Y gastric bypass - complication and treatment

A

Complication: stomal (anastomotic) stenosis
Treatment: EGD visualization and balloon dilation; surgery if failed

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38
Q

What causes exacerbation of Gilbert syndrome?

A

Stressors:
Febrile illness
Fasting
Vigorous exercise
Surgery

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39
Q

Describe the watershed lines of the colon that are at highest risk of ischemic colitis

A

Splenic flexure - watershed between superior and inferior mesenteric arteries

Rectosignmoid junction - watershed between sigmoid artery and superior rectal artery

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40
Q

Ischemic colitis - appearance on endoscopy

A

Pale mucosa with petechial bleeding
Bluish hemorrhagic nodules
Cyanotic mucosa with hemorrhage

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41
Q

Mallory-Weiss tear - risk factors, dx, treatment

A

Risk:
Alcohol use disorder
Hiatal hernia
Dx: Endoscopy
Tx: Endoscopic electrocoagulation or local injection of epinephrine

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42
Q

Abdominal compartment syndrome - causes, measurement?

A

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)

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43
Q
A
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44
Q

Infliximab

A

TNF-a receptor antagonist for Crohn

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45
Q

Adalimumab

A

TNF-a antagonist for Crohn

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46
Q

Toxic megacolon can complicate which conditions?

A
  1. Ulcerative colitis
  2. C diff
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47
Q

Describe biliary colic

A

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

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48
Q

Gastroparesis symptoms

A
  1. Bloating
  2. Early satiety
  3. Postprandial emesis
  4. Food aversion
  5. Weight loss

Can occur via vagal nerve injury after Nissen fundoplication

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49
Q

Explain enteric hyperoxaluria

A

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

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50
Q

Iliocecal resection increases risk of what?

A

Small intestinal bacterial overgrowth - no ileocecal valve allows colonic bacteria to enter SI

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51
Q

SI bacterial overgrowth - diagnosis

A

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

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52
Q

Fecal elastase test

A

Sensitive/specific indirect test for pancreatic function - low in chronic pancreatitis

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53
Q

Hepatic angiosarcoma - epi

A

Older men exposed to toxins (e.g. vinyl chloride gas, inorganic arsenic compounds, thorium dioxide)

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54
Q

Which distal LN can abdominal cancers typically spread to?

A

Thoracic duct to left supraclavicular LN (Virchow node)

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55
Q

Ursodeoxycholic acid - indications

A
  1. Cholesterol gallstones
  2. PBC or PSC - slow disease progression
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56
Q

How would abscess appear on CT?

A

Hypodense, round, well-defined, with surrounding abscess membrane

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57
Q

Explain the different kinds of esophageal dysphagia

A

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
Q

Eosinophilic esophagitis - appearance and treatment

A

Furrowing, small whitish exudates, multiple stacked ring-like indentations (trachealization)

Treatment:
1. Dietary
2. PPI
3. Topical glucocorticoids (swallowed fluticasone spray, budesonide)

59
Q

Colovesical fistula - etiologies, imaging

A

Diverticular disease, Crohn, colorectal malignancy
CT with oral or rectal contrast, followed by colonoscopy to rule out malignancy

60
Q

Sphincter of Oddi dysfunction - signs, concerns, dx, treatment

A

Feels like biliary colic but after cholecystectomy
Opioids can increase sphincter contraction and precipitate pain
Manometry for diagnosis, sphincterotomy for treatment

61
Q

Colon cancer - when surgery, when chemo and/or radiation?

A

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
Q

Contained appendiceal abscess should be managed how?

A

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
Q

What is primary sclerosing cholangitis associated with?

A

Underlying ulcerative colitis (90%)
High risk of cholangiocarcinoma

64
Q

Cholangiocarinoma risk is greatest in whom?

A

Fibropolycystic liver disease
Primary sclerosing cholangitis

65
Q

How does IBD cause toxic megacolon?

A

Inflammatory mediator-induced increase in NO production –> smooth muscle dilation

Extension of mucosal inflammation into smooth muscle layer –> muscle paralysis and dilation

66
Q

When is diagnostic peritoneal lavage used?

A

If hemodynamically unstable, no peritonitis and no/inconclusive free fluid on FAST, and too unstable for CT

67
Q

Air in intrahepatic bile ducts

A
  1. Emphysematous cholecystitis
  2. Cholecystoenteric fistula (can lead to gallstone ileus)
68
Q

Why is gallstone ileus a misnomer?

A

It is not a functional disruption of motility, but rather a mechanic bowel obstruction

69
Q

Cecal or sigmoid volvulus in younger patients?

A

Cecal - often report prior self-resolving episodes because many have congenital mobile cecum (i.e. mesentery failed to fuse with parietal peritoneum)

70
Q

Cecal or sigmoid volvulus - which one endoscopic detorsion vs surgery?

A

Sigmoid volvulus endoscopic detorsion first-line - much higher success rate

71
Q

Mandibular tori

A

Benign bony growths (exostoses) that protrude from mandible

More common than palatal tori - midline, symmetric, bony lesions on hard palate

72
Q

When to drain diverticular abscess?

A

> =4 cm; place under CT or ultrasound guidance

73
Q

When are peripheral mu-opioid receptor antagonists used for opioid-induced constipation?

A

Those who have failed conventional laxatives

Ex. Methylnaltrexone, naloxegol, naldemedine

74
Q

Most cases of vitamin K deficiency develop in whom?

A

Disorders of pancrease/biliary system (vitamin K is fat-soluble)
Prolonged courses of antibiotics

75
Q

Proximal vs mid/distal SBO

A

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
Q

Name the retroperitoneal GI structures

A

Latter duodenum, ascending and descending colon, pancreas head/body - these are all secondarily retroperitoneal

Esophagus, rectum - primarily retroperitoneal

77
Q

IBS treatment

A

Loperamide + low FODMAP diet:
Fermentable Oligosaccharides, Disaccharides, Monosaccharides, And Polyols

78
Q

Tumor proximal vs distal to anal dentate line - which draining LN?

A

Proximal: internal iliac, inferior mesenteric LN
Distal: inguinal LN

79
Q

What lab particularly predicts pancreatitis mortality?

A

BUN

80
Q

What is stool elastase a marker for?

A

Pancreatic exocrine function - low levels suggestive of chronic pancreatitis

81
Q

Diffuse esophageal spasm medical treatment

A

CCB (eg diltiazem)

82
Q

Primary billiary cholingitis treatment

A

Ursodeoxycholic acid:
More hydrophilic and prevents Injury from endogenous bile acids
Increases billiary secretion
Immunomodulatory effects

83
Q

What is S gallolyticus infective endocarditis associated with?

A

Colorectal cancer, IBD

Perform colonoscopy, LFTs, hepatitis serology

84
Q

MALT tumors are associated overwhelmingly with what?

A

H. pylori - treat with quadruple therapy

If negative, treat with radiotherapy, immunotherapy (eg rituximab), or single-agent chemo

85
Q

Pernicious anemia is related to risk of what GI cancers?

A

Gastric adenocarcinoma
Gastric carcinoid

86
Q

Spontaneous bacterial peritonitis - diagnosis

A

PMN >=250 in ascitic fluid
Supported by SAAG >=1.1, protein <1

87
Q

Primary biliary cholangitis - comorbidities

A
  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
Q

Primary biliary cholangitis - treatment

A

Ursodeoxycholic acid

89
Q

Most common inciting factors of hepatorenal syndrome

A

GI bleeding
SBP

90
Q

Hepatorenal syndrome - temporizing treatment

A

Splanchnic vasoconstrictors - midodrine, terlipressin, or norepinephrine + octreotide, as well as albumin

91
Q

What medications cause esophagitis?

A

Tetracyclines (acid effect)
Bisphosphonates
Potassium chloride (osmotic injury), iron
Aspirin/NSAIDs (disruption of protective layer)

92
Q

Treatment for triglyceride induced pancreatitis

A

Triglycerides >1,000

Insulin therapy or apheresis

93
Q

Patients with upper but not lower GI bleed have what lab result?

A

Elevated BUN and BUN/Cr ratio

Potentially due to increased urea production from intestinal breakdown of Hgb, as well as hypovolemia

94
Q

Vitamin B12 deficiency is rare in alcoholics except for those who also have…

A

Chronic pancreatitis

95
Q

What liver issue can cause splenic platelet trapping with thrombocytopenia and hepatosplenomegaly?

A

Cirrhosis

96
Q

Alcoholic liver disease would have what else elevated?

A

GGT, ferritin

97
Q

Boerhaave pleural effusion is most likely on what side?

A

Left - due to intrinsic weakness of left posterolateral aspect of distal intrathoracic esophagus

98
Q

How can cirrhosis affect a male specifically?

A

Hypogonadism - due to primary gonadal injury or hypothalamic-pituitary axis dysfunction

Also elevated estradiol due to increased conversion from androgens

99
Q

Inflammatory diarrhea vs regular diarrhea

A

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
Q

Medications that cause intraphepatic cholestasis

A

Certain antibiotics (e.g. macrolides)
Anabolic steroids
Oral contraceptives

100
Q

Clues to eosinophilic esophagitis

A

Heartburn that doesn’t respond to standard GERD meds
Manometry showing esophageal hypercontractility

101
Q
A
102
Q

Do prokinetic agents help prevent aspiration pneumonia?

A

No - use thickened liquids in chin-down position and bed elevation to 30-45 degrees

103
Q

Differentiate SAAG between ascites and HF/venoocclusive/pericardial disease

A

SAAG >=1.1 for all, but ascites protein <2.5 in cirrhosis and >=2.5 in others

104
Q

SBP ascites

A

PMN >=250
SAAG >=1.1
Protein <1

105
Q

Green/black stools ico poisoning

A

Acute iron poisoning - color caused by disintegrating iron tablets

106
Q

Proctalgia fugax

A

Recurrent, brief episodes of rectal pain unrelated to defecation

Functional pathology

Treat with reassurance
Refractory: Nitroglycerin cream +/- biofeedback therapy

107
Q

Signs of diarrhea due to laxative abuse

A

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
Q

Tea-colored stools

A

VIPoma

109
Q

When does hemochromatosis present in women?

A

After menopause - menstruation slows iron accumulation

110
Q

What is jejunal aspiration used for?

A

SIBO diagnosis

111
Q

What are examples of pseudodiverticula?

A

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
Q

Esophageal webs are associated with…

A

Plummer-Vinson syndrome:
Iron deficiency anemia
Glossitis

113
Q

Diffuse esophageal spasm - treatment

A

CCBs
TCAs
Nitrates

114
Q

Who should undergo endoscopy for dysphagia?

A

All >60 yo
Red flags if <60 yo

115
Q

Type A (fundal) vs Type B (antral) chronic gastritis

A

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
Q

H pylori urea breath or stool antigen test - which is more sensitive?

A

Stool

117
Q

MALT lymphoma is associated with…

A

Chronic H pylori
Treat with triple therapy

118
Q

Zollinger-Ellison causes what electrolyte imbalance?

A

Hypercalcemia from hyperPTH

119
Q

Which diabetes drugs can worsen gastroparesis?

A

Pramlintide
GLP-1 agonists

120
Q

PAS+ stain granules in lamina propria, arthritis, LAD, carsiac issues

A

Whipple disease

121
Q

Carcinoid syndrome can result in what vitamin deficiency?

A

Niacin/B3 (4 Ds) - tryptophan needed for both niacin and serotonin

122
Q

IBS-C vs IBS-D treatment

A

IBS-C:
Cl channel activators (lubiprostone)
Guanylate cyclase activators (linaclotide, plecanatide)

IBS-D:
Rifaximin

Both: TCA or SNRIs

123
Q

Colon cancer screening guidelines for other scenarios

A

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
Q

Gardner syndrome

A

FAP + osteomas (skull, facial bones) + fibromatosis
Hypertrophy of retinal pigment epithelium

125
Q

FAP + brain tumors (neurologic signs)

A

Turcot syndrome

126
Q

Acute vs chronic radiation proctitis

A

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
Q

Ulcerative colitis 5-ASA agents used (not in Crohn)

A

Sulfasalazine, mesalamine

128
Q

Hep B - markers of carrier vs transmissibility

A

Persistent surface Ag: carrier
Persistent e Ag: high transmissibility

129
Q

Best test of acute HAV

A

IgM HAVAb

130
Q

Valproic acid overdose hepatitis - treatment

A

L-carnitine

131
Q

Nephrotic syndrome ascites

A

SAAG <1.1 (conditions not related to portal HTN)
Albumin <2.5 (as is cirrhosis)

132
Q

SBP prophylaxis

A

Bactrim or fluoroquinolone - can give for cirrhotic patient admitted for GI bleed/variceal hemorrhage

133
Q

Hepatorenal syndrome - treatment

A

Octreotide (splanchnic vasodilation)
Midodrine (increase BP)

May require dialysis

134
Q

Which clotting factor is not low in cirrhosis?

A

Factor 8

135
Q

NASH management

A

Vitamin E
Pioglitazone

136
Q

Wilson disease - treatment

A

Penicillamine or trientine (copper chelators)
Zinc (increases fecal excretion)
Dietary restriction

137
Q

Focal nodular hyperplasia vs hepatic hemangioma vs hepatic adenoma

A

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
Q

Scorpion sting can cause what GI issue?

A

Acute pancreatitis

139
Q

Alternating stenosis and dilation of main pancreatic duct (chain of lakes)

A

Chronic pancreatitis

140
Q

D cell tumor is…

A

Somatostatinoma - usually found in head of pancreas
Whipple procedure if not metastatic, octreotide to manage symptoms

Internal Medicine (23 decks)

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