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Surgery Rotation EORE > GI > Flashcards

GI Flashcards

1
Q

what is acute cholecystitis caused by?

A

sustained obstruction of cystic duct

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2
Q

how is acute cholecystitis different from acute cholangitis?

A

by lack of biliary obstruction & jaundice (cholangitis has this)

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3
Q

what are the s/s of acute cholecystitis?

A

localizing constant RUQ pain/epigastrium

pain lasts >3-4 hrs

N/V, systemic sx’s of infam -> fever, tachycardia

pt stays still b/c pain aggravated by movement

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4
Q

what is a sign of perforation in acute cholecystitis?

A

hypoactive bowel sounds

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5
Q

what is Boas sign?

A

radiation of pain d/t phrenic nerve irritation in acute cholecystitis
(pain radiates from RUQ to scapula)

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6
Q

what are the labs like for acute cholecystitis?

A

LEUKOCYTOSIS W/ LEFT SHIFT

mild incr. in AST/ALT

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7
Q

what’s the initial test of choice for acute cholecystitis?

A

U/S (shows distended gallbladder and thickened GB wall)

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8
Q

what’s the GOLD STANDARD to dx acute cholecystitis?

A

HIDA scan (aka cholescintigraphy) - see non visualization of GB suggesting cystic duct obstruction

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9
Q

what’s the tx for acute cholecystitis?

A

NPO, IVFs, IV abx (3rd gen CPN & Flagyl)

Lap chole (after IVF and abx tx)

Cholecystostomy (if too ill for cholecystectomy)

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10
Q

what is the MOST COMMON bacteria in acute cholecystitis? other bacteria?

A

MC = E. coli

others: Klebsiells, enterococci, b. frag, clostridium

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11
Q

what can chronic cholecystitis lead to?

A

gallbladder cancer (d/t chronic inflammation of GB)

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12
Q

what’s the s/s of chronic cholecystitis?

A

Biliary colic = classic & MC sx

NO FEVER/CHILLS (NO INFECTION)

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13
Q

which has FEVER/CHILLS - signs of infection…acute or chronic cholecystitis?

A

acute cholecytitis

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14
Q

what’s the labs like for chronic cholecystitis?

A

normal CBC w/diff (no leukocytosis)

LFTs normal

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15
Q

how is chronic cholecystitis distinguished from acute cholecystitis?

A

by sx’s and absence of leukocytosis

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16
Q

what’s the preferred imaging for dx of chronic cholecystitis?

A

U/S

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17
Q

what’s the tx of chronic cholecystitis?

A

IV analgesics & observation

Elective cholecystectomy (after confirm dx)

Intra-op cholangiogram

Lithotripsy w/ bile salts (chenodeoxycholic & ursodeoxycholic acid) -> takes 2 years, if can’t do surgery

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18
Q

what’s the MC cause of acute pancreatitis? after that?

A

MCC is gallstones

after is ETOH abuse (chronic)

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19
Q

what’s the s/s of acute pancreatitis?

A

abrupt onset of non-cramps, epigastric abd pain that radiates to the back

pain alleviated by sitting forward or standing

N/V, anorexia, jaundice (d/t biliary obstruction)

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20
Q

the pain in acute pancreatitis is alleviated by what?

A

sitting forward or standing

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21
Q

what’s the labs like for acute pancreatitis?

A

Amylase/Lipase >3x ULN
-or elevated amylase 1.5x ULN w/ lipase of 5x ULN

Fasting Tg >1,000

Leukocytosis

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22
Q

what imaging is done to dx acute pancreatitis?

A

CT w/ IV contrast

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23
Q

what’s the tx for acute pancreatitis?

A

dmit to hospital, NPO, IVFs, analgesia with Meperidine (not morphine b/c incr. spasm of sphincter of Oddi), antiemetic IV

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24
Q

when is surgery done for acute pancreatitis?

A

if dx uncertainty and to prevent further attacks of acute pancreatitis

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25
Q

what surgeries are done for acute pancreatitis?

A

If mild-mod pancreatitis d/t cholelithiasis → undergo cholecystectomy during admission

If choledocholithiasis → ERCP w/ sphincterotomy & stone extraction done pre-op to clear CBT

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26
Q

what is chronic pancreatitis?

A

irreversible damage to pancreas

occurs after multiple acute attacks, causing pancreatic ductal system to become permanently damaged

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27
Q

what insufficiencies occur in chronic pancreatitis?

A

endocrine & exocrine and are manifested by DM and steatorrhea

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28
Q

causes of chronic pancreatitis?

A

ETOH abuse = MC

smoking, CF, autoimmune

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29
Q

what are the s/s of chronic pancreatitis?

A

dull epigastric pain that radiates tot he back (improved by leaning forward) that starts out intermittent, then becomes constant

malnutrition & fat-soluble vit. deficiencies d/t malabsorption 2/2 exocrine insufficiency and steatorrhea

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30
Q

what are the labs for chronic pancreatitis?

A

Secretin test -> Abnl if >60% dysfxn (checks digestive enzyme fxn b/c secretin stimulates their secretion from the pancreas)

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31
Q

what’s the tx for chronic pancreatitis?

A

change diet to decrease fat and ETOH

***pancreatic enzyme replacement for steatorrhea

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32
Q

what are the MC anal abscesses?

A

perianal and ischiorectal

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33
Q

what is a perianal abscess?

A

early intersphincteric abscess increases in size

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34
Q

what is a ischiorectal anal abscess?

A

in ischiorectal fossa located outside external sphincter & below elevator ani muscles

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35
Q

what’s a supralevator anal abscess?

A

abscess spreads above elevators (hard to dx)

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36
Q

what’s an intersphincteric anal abscess?

A

abscess b/w external and internal anal sphincters

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37
Q

what are the s/s of anal abscess?

A

***Cardinal signs of infection present: fever, redness, swelling

***Extreme perirectal pain that won’t let pt sit down or have BMs

Hard to see swelling on early intersphincteric and supralevator

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38
Q

what are the classic PE findings for anal abscess?

A

rubor, dolor, calor, tumor (heat, pain, redness, swelling)

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39
Q

what’s the tx for anal abscess?

A

I&D of abscess
-if perianal or ischiorectal abscess -> drain thru skin (simple)

-if perirectal, intersphincteric, supralevator abscess -> draining OR (complicated)

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40
Q

what are anal fistulas?

A

from anal abscess ater drainage

Abnl. communication b/w anus at level of dentate line & the perirectal skin, thru the bed of a the previous abscess

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41
Q

what is an intersphincteric fistulae?

A

results of perinanal abscess

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42
Q

what is a transsphincteric fistulae?

A

result of ischiorectal abscess

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43
Q

what is a suprasphincteric fistulae?

A

result of supralevator abscess

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44
Q

what’s the sx’s of anal fistulas?

A

chronic drainage of pus, fecal soiling, occasional perineal discomfort

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45
Q

what’s goodsall’s rule?

A

to predict trajectory of the fistulous tract & location of the internal anal opening

Fistulas w/ext. opening anteriorly to anal line, connect to internal opening by short radial straight tract

Fistulas w/ext. opening posteriorly to anal line connect to internal opening by curvilinear fashion to posterior midline

Exception: ant. fistulas lying >3 cm from anus, may have curved track (sim. to post. fistulas)

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46
Q

what’s the tx for anal fistulas?

A

Fistulotomy (unroof fistula tract) - careful about cutting sphincter -> incontinence (use seton stitch to avoid incontinence)

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47
Q

where are most anal fissures located?

A

posterior midline

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48
Q

what’s the tx for anal fissures? (acute and chronic fissures)

A

Acute fissures:
-conservative tx, avoid diarrhea/constipation, bulk laxative, top. nitro, top. procainamide, botox, sitz bath, top. CCB

Failure of conservative tx or chronic fissures:
-Surgery -> partial lateral internal sphincterotomy

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49
Q

what are the two types of anorexia?

A

restrictive type and purging type

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50
Q

what’s the BMI or body weight to dx anorexia?

A

BMI < 17.5 kg/m2 or body weight <85% of ideal weight

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51
Q

what is seen on PE for anorexia?

A

emaciation, hypotension, bradycardia, skin/hair changes (ex. lanugo), dry skin, salivary gland hypertrophy, amenorrhea, arrhythmias, osteoporosis

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52
Q

what’s the labs like for anorexia?

A

leukocytosis, leukopenia, anemia; hypokalemia, incr. BUN (dehydration), hypothyroidism

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53
Q

what syndrome can occur in anorexia?

A

refeeding syndrome

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54
Q

what’s the HALLMARK and predominant cause of refeeding syndrome?

A

hypohosphatemia

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55
Q

what’s the tx for anorexia?

A
  1. Medical stabilization: hospitalization for <75% expected body weight or pts who have medical complications
  2. Psychotherapy: CBT, supervised meals, weight monitoring
  3. Pharmacotherapy: if depressed → SSRIs; atypical antipsychotics +/- b/c can also help w/ weight gain
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56
Q

when do you hospitalize a pt for anorexia?

A

for <75% expected body weight or pts who have medical complications

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57
Q

what’s the pre-op abx for appendicitis if not perfed?

A

single dose Cefotetan 2g IV
(covers GN aerobic bacteria)

if PCN/CPN allergy -> Clinda + Cipro or Levo or Gentamicin or Aztreonam

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58
Q

when do you NOT operate for appendicitis?

A

peritonitis, appendicular mass, resolved

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59
Q

what’s the most common complication of appendectomy?

A

post-op wound infection

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60
Q

what are the most important vitamin deficiencies in bariatric surgery?

A

iron, vit B12, folic acid, thiamine, Ca, vit D

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61
Q

what’s the MOST COMMON vitamin deficiency in gastric bypass patients?

A

iron deficiency

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62
Q

what’s the MC cause of SBO in first world? MC in third world??

A

post-surgical adhesions = MC cause in 1st world

incarcerated hernia = MC cause in 3rd world

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63
Q

what are the top 3 MC causes of SBO?

A

post-surgical adhesions, incarcerated hernia, metastatic peritoneal cancer

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64
Q

what’s the MC cause of large bowel obstructions?

A

malignancy

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65
Q

which type of SBO is at high risk for strangulation and requires IMMEDIATE surgery?

A

Closed loop SBO (lumen occluded at 2 points, reducing blood supply, causing strangulation, necrosis & peritonitis)

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66
Q

what’s the difference b/w distal and partial SBO’s on presentation?

A

distal presents more with abdominal distention & less vomiting

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67
Q

what are the 4 hallmark sx’s of SBO?

A
  1. Cramping abdominal pain (colicky abd pain in periumbilical region that becomes more severe & constant)
  2. Abdominal distention (the more distal the more prominent)
  3. Vomiting (may be bilious if proximal, follows the abdominal pain)
  4. Obstipation (late finding)
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68
Q

what are signs of high grade obstruction?

A

constipation and obstruction

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69
Q

what’s the PE like for SBO?

A

abdominal distention, hyperactive bowel sounds in early obstruction -> HIGH-PITCHED TINKLES ON AUSCULTATION & VISIBLE PERISTALSIS

No bowel sounds occur late in obstruction

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70
Q

what’s the initial dx study for SBO?

A

abdominal (KUB) x-ray

-see air fluid levels in step ladder pattern

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71
Q

what imaging is done after abd x-ray for SBO for further localization?

A

CT with water soluble PO contrast

-failure of contrast to reach cecum in 4 hrs -> SURGERY

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72
Q

SBO in the absence of prior abdominal surgery should trigger what type of work-up?

A

a malignancy work-up

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73
Q

what electrolyte abnormality is common in SBO?

A

hypokalemia, “contraction” alkalosis w/ advanced dehydration

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74
Q

what’s the tx for SBO if non-strangulated?

A

IVF, NPO with NGT decompression

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75
Q

what’s the tx for SBO if strangulated?

A

surgery

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76
Q

if pt with SBO doesn’t get surgery, but there’s no improvement of sx’s in = 24-48 hrs, what’s the tx?

A

surgery (d/t incr. risk of bowel ischemia)

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77
Q

what abx are used for SBO with surgery?

A

3rd gen CPN like cefdinir, cefpodoxime + flagyl (covering GN aerobes and anaerobes)

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78
Q

what is the MC cause of large bowel obstruction? others?

A

adenocarcinoma = MCC

Others = Scarring a/w diverticulitis and volvulus

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79
Q

what’s the s/s of large bowel obstruction?

A

abd distention, cramping abd pain in hypogastrium, N/V, obstipation

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80
Q

what’s the dx for large bowel obstruction?

A

Plain abd films (if see obstruction, no barium enema)

Water-soluble contrast barium enema confirms dx and show exact location

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81
Q

what’s the tx for partial LBO?

A

NGT decompression and IVF

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82
Q

what’s the tx for complete LBO?

A

emergent surgery

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83
Q

what is a volvulus?

A

twisting of any part of the bowel (at its mesenteric attachment site)

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84
Q

what’s the MC site of a LBO?

A

sigmoid colon

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85
Q

what’s the MC sites of volvulus?

A

sigmoid (70%) and cecum (30%)

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86
Q

what’s the 2nd MC cause of complete colonic obstruction?

A

volvulus

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87
Q

what are risk factor for volvulus?

A

stretching and elongation of sigmoid w/ age

common >/= 65 y/o

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88
Q

what’s the s/s of volvulus?

A

Obstructive sx’s:

-massive abd distention, vomiting, abd pain, obstipation, tachypnea

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89
Q

what’s the PE like for volvulus?

A

distention, tympany, high-pitched tinkling sounds and rushes

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90
Q

what’s the dx imaging for volvulus?

A

Abd x-rays
-show massively dilated cecum or sigmoid w/out hausfrau that assume a KIDNEY BEAN APPEARANCE

Water-soluble contrast enema
-shows exact site of obstruction -> characteristic funnel-like narrowing that resembles BIRD’S BEAK OR AN ACE OF SPADES

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91
Q

what do the abd x-rays show for volvulus?

A

kidney bean appearance (no hausfrau on cecum or sigmoid and they are dilated)

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92
Q

what does water-soluble contrast enema show for volvulus?

A

shows exact site of obstruction -> characteristic funnel-like narrowing that resembles BIRD’S BEAK OR AN ACE OF SPADES

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93
Q

kidney bean appearance on abd x-rays means what?

A

volvulus

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94
Q

bird’s beak or ace of spades appearance on water-soluble contrast enema means what?

A

volvulus

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95
Q

what’s the initial tx for volvulus?

A

sigmoidoscopy with rectal tube insertion to decompress sigmoid volvulus

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96
Q

how are cecal volvulus treated?

A

always treated surgically with right hemicolectomy with ileotransverse colostomy

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97
Q

how are sigmoid volvulus treated?

A

easily decompressed and req. elective resection, except for high-risk elderly pts

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98
Q

what is cholangitis?

A

biliary tract infection from obstruction (occurs from choledocholithiasis)

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99
Q

what’s the clinical manifestations of cholangitis?

A

Charcot’s triad:
-jaundice, RUQ pain, fever

Reynold’s Pentad:
-Charcot’s triad + hypotension & AMS

Light colored stools, dark tea-colored urine

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100
Q

when does Reynold’s Pentad occur?

A

in cholangitis if pus (in addition to the stones) develops -> acute suppurative cholangitis

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101
Q

what are the strongest risk factors for gallbladder disease?

A

Native American and family history

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102
Q

what’s the PE like for Cholangitis?

A

RUQ pain

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103
Q

what’s the labs like for cholangitis?

A

Leukocytosis (very high)

Elevated total bilirubin (d/t bile duct obstruction)

Elevated ALP (means inflammation/irritation of ductal system) and GGT

Mild elevation of AST/ALT

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104
Q

what’s the gold standard imaging for cholangitis?

A

Cholangiography via ERCP -> draining the CBD

do PTC if can’t do ERCP

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105
Q

what’s the tx for cholangitis?

A

URGENT INTERVENTION & MONITORING IN ICU

IVFs, NPO, abx (broad spectrum covering GN rods)
-Ampicillin/Sulbactam, Piperacillin/tazobactam or Ceftriaxone + Metronidazole or FQ + Metro

***ERCP → CBD decompression/stone extraction

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106
Q

when will patient with cholangitis get a cholecystectomy?

A

after they recover from the acute cholangitis episode

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107
Q

what’s the risk factors for cholelithiasis?

A

Fat, fertile, forty, female, fair

Native American

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108
Q

what d/o’s produce pigment stones instead of cholesterol stones?

A

hemolytic d/o’s & alcoholic cirrhosis

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109
Q

what are the labs like for cholelithiasis?

A

all normal

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110
Q

what’s the initial study of choice for cholelithiasis?

A

U/S

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111
Q

what’s the tx for choelithiasis?

A

Lap cholecystectomy if symptomatic

Elective cholecystectomy if asymptomatic

Lithotripsy w/ bile salts (chenodeoxycholic & ursodeoxycholic acid) → takes 2 years, if can’t do surgery

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112
Q

what is choledoclithiasis?

A

when stones pass thru cystic duct & enter CBD

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113
Q

what’s the s/s of choledoclithiasis?

A

If stone obstructs bile duct → jaundice w/ light-colored stools and dark, tea-colored urine

Jaundice may fluctuate in intensity (vs progressive jaundice caused by malignant disease)
Same sx’s as cholelithasis

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114
Q

what are 3 causes of total bilirubin increase?

A

hemolytic anemia (sickle cell), Gilbert Syndrome, Cholangitis (obstruction)

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115
Q

what’s the PE like for choledoclithiasis?

A

abd unremarkable or tenderness in RUQ if cholangitis is present

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116
Q

what’s the labs like for choledoclithiasis?

A

Significant elevation in serum bilirubin

Increased ALP, GGT

Mild elevation of AST/ALT

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117
Q

what’s the dx test of choice for choledoclithiasis?

A

ERCP (can be used for both dx and stone extraction)

transabdominal U/S (for initial dx)

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118
Q

what’s the treatment for choledoclithiasis?

A

Elective (if no cholangitis) ERCP and sphincterotomy for removal of stones from common bile duct

Elective cholecystectomy

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119
Q

what are congenital “true” diverticula and where in the colon are they found?

A

full wall thickness in the diverticular sac

uncommon, but when present are found in the cecum and ascending colon

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120
Q

what are acquired (False) diverticula and where are they found?

A

common in western countries

involve the sigmoid colon

mucosal herniations thru the muscular wall

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121
Q

what is diverticulosis?

A

presence of multiple FALSE diverticula int he colon

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122
Q

what’s the MC cause of LGIB?

A

diverticulosis

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123
Q

what’s the s/s of diverticulosis?

A

Recurrent abdominal pain, localized to the LLQ (sigmoid area)

Functional changes in bowel habits - bleeding, constipation, diarrhea, alternating constipation and diarrhea

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124
Q

what’s the PE like for diverticulosis?

A

Unremarkable (usually), may show mild tenderness in LLQ

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125
Q

what’s the dx like for diverticulosis?

A

NO LEUKOCYTOSIS OR FEVER

Segmental spasm and luminal narrowing on radiograph

Endoscopic eval shows openings of diverticula

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126
Q

what’s diverticulosis a/w?

A

low fiber diet, constipation, obesity

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127
Q

what area is the most common for diverticulosis?

A

sigmoid colon

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128
Q

what’s the tx for diverticulosis?

A

high fiber diet, fiber supplements (psyllium)

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129
Q

what is diverticulitis initiated by?

A

obstruction of the neck of the diverticulum by a fecalith

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130
Q

what’s the HALLMARK s/s of diverticulitis?

A

LLQ pain (subacute onset), alteration in bowel habits (constipation or diarrhea), fever

***LLQ pain = MC

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131
Q

where is the pain localized in diverticulosis/diverticulitis?

A

LLQ (sigmoid area)

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132
Q

what are complications of diverticulitis?

A

perf, abscess, obstruction, fistula

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133
Q

what’s the PE like for diverticulitis?

A

LLQ pain, fever, palpable mass (MC PE finding)

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134
Q

what’s the imaging test of choice for diverticulitis?

A

CT scan

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135
Q

increased ___ cells in diverticulitis

A

white blood cells

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136
Q

what’s the tx for diverticulitis?

A

admit pt, NPO clear liquid diet, IV antibiotics (Cipro or Bactrim + Metro) for 5-7 days

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137
Q

do patients with diverticulitis need surgery?

A

most pts don’t need surgery unless they have recurrent bouts several times a year or a fistula

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138
Q

what’s the s/s of diverticular bleeding?

A

BRBPR

***PAINLESS HEMATOCHEZIA

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139
Q

from where does diverticular bleeding occur?

A

distal to ligament of Treitz

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140
Q

how do you determine if LGIB or UGIB?

A

NGT

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141
Q

if diverticular bleeding, what dx test is done?

A

colonoscopy

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142
Q

what’s the tx for diverticular bleeding?

A

most diverticular bleeding stops out intervention

MESENTERIC ANGIOGRAPHY is useful in detecting source (can also be used in tx w/ Vasopressin

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143
Q

what’s the MC cause of esophageal cancer worldwide and in AAs and males?

A

squamous cell carcinoma

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144
Q

what’s the MC cause of esophageal cancer in US, younger pts, NAs, whites, Europe?

A

adenocarcinoma

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145
Q

which type of esophageal cancer is a/w Barrett’s esophagus from GERD?

A

adenocarcinoma esophageal cancer

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146
Q

where in the esophagus does SCC occur?

A

upper 1/3 of esophagus

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147
Q

what are the RF’s for SCC esophageal cancer?

A

tobacco/ETOH use, exposure of esophagus to noxious stimuli, AA’s

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148
Q

where in the esophagus does adenocarcinoma esophageal cancer occur?

A

lower 1/3 (distal esophagus)

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149
Q

what is adenocarcinoma esophageal cancer a complication of?

A

GERD leading to Barrett’s esophagus

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150
Q

what are the MC sites of mets for esophageal cancer?

A

LNs, liver, and lungs

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151
Q

what’s the s/s of esophageal cancer?

A

***progression of dysphagia from solid foods to liquids

weight loss, chest pain

h/o GERD for adenocarcinoma

h/o smoking and alcohol abuse for SCC

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152
Q

what’s the difference in presentation b/w adenocarcinoma and SCC esophageal cancer?

A

Adenocarcinoma pts have h/o GERD
Pts usually healthier, less advanced disease (b/c undergoing surveillance endoscopy of Barrett’s)

SCC present more with advanced disease, greater weight loss, and h/o smoking and alcohol abuse

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153
Q

what’s the initial dx study for esophageal cancer?

A

barium swallow to evaluate the cause of dysphagia

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154
Q

what’s the dx test of choice for esophageal cancer?

A

upper endoscopy with biopsy for histologic confirmation

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155
Q

what’s the tx for esophageal cancer?

A

surgical resection of tumor = best chance for cure

do complete local resection of the tumor w/ reconstruction of the alimentary tract by using stomach (MC), or left colon, or jejunum

chemotherapy

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156
Q

what are esophageal strictures?

A

narrowing of lumen of esophagus

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157
Q

what’s the MC cause of esophageal strictures?

A

untreated GERD -> peptic strictures

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158
Q

what’s the s/s of esophageal strictures?

A

***Slowly progressive food DYSPHAGIA, odynophagia, heartburn, heart burn, and episodic food impaction

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159
Q

what’s dx imaging for esophageal strictures?

A

***endoscopy = initial test

barium esophagram = initial test ONLY if h/o or sx’s of a proximal esophageal lesion or known stricture from XRT tx or caustic ingestion

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160
Q

what’s the tx for esophageal strictures?

A

***PPIs

Diet - GERD restrictions, weight loss, small meals & eat slowly, avoid meds that cause pill esophagitis

***Esophageal dilation and resection of cancer

***treat the underlying cause

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161
Q

what are causes of esophageal strictures/

A

GERD (peptic strictures), Zollinger-Ellison, Tumor (adenocarcinoma), Caustic ingestion, XRT, infectious esophagitis, pill esophagitis

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162
Q

what’s the MC type of gastric cancer world wide?

A

adenocarcinoma

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163
Q

what’s the most frequent type of gastric cancers?

A

ulcerative carcinomas

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164
Q

what’s the most important RF for gastric cancer?

A

H. pylori

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165
Q

what are RFs for gastric cancer?

A

H. pylori (most impt.), salted, cured, smoked, pickled foods containing nitrites/nitrates

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166
Q

what are the 2 types of gastric adenocarcinoma?

A

intestinal and diffuse

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167
Q

what’s intestinal gastric adenocarcinoma?

A

Well differentiated w/ glandular elements

More common in regions w/ a high incidence of disease

Occurs in older pts & spreads hematogenously

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168
Q

what’s diffuse gastric adenocarcinoma?

A

Poorly differentiated w/ characteristic signet ring cell

Occurs in younger pts and a/w w/ blood type A

Spreads via lymphatics and local extension

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169
Q

what’s the s/s of gastric adenocarcinoma?

A

***Dyspepsia, weight loss, early satiety, epigastric pain, unexplained weight loss

***Hematemesis, melena

***New onset Fe def. anemia (d/t bleeding

***Signs of Mets

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170
Q

what are the signs of Mets for gastric adenocarcinoma?

A

***supraclavicular LN (virchows node)

***umbilical LN (sister Mary Josephs node)

palpable nodule on rectal exam (Blumer’s shelf)

Ovarian METS (Krenburg tumor)

left axillary LN (Irish sign)

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171
Q

what’s the dx for gastric adenocarcinoma?

A

upper endoscopy with biopsy

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172
Q

what is Linitis plastica?

A

diffuse thickening of the stomach wall (“leather bottle” appearance) d/t complete cancer infiltration of the stomach

***WORSE TYPE OF GASTRIC ADENOCARCINOMA

173
Q

what’s the tx for gastric adenocarcinoma?

A

gastrectomy, XRT, and chemo (both adenocarcinoma & lymphoma) -> poor prognosis

174
Q

what’s the MC site of extra nodal mets in NHL?

A

stomach (gastric lymphoma)

175
Q

what is Barrett’s esophagus?

A

complication of GERD

esophageal squamous epithelium replaced by columnar epithelium cells from the stomach

176
Q

what are the typical sx’s of GERD?

A
  • **HEARTBURN = hallmark
  • incr. w/supine pos. & relieved w/ antacids

Regurgitation (sour taste in mouth), dysphagia, cough at night (acid going into lungs and irritating them)

177
Q

what are the atypical sx’s of GERD?

A

hoarseness, aspiration pneumonia, “asthma” (bronchospasm from acid contact w/ the lung

Noncardiac chest pain (MC cause of non cardiac chest pain)

178
Q

what’s the MCC of non-cardiac chest pain?

A

GERD

179
Q

what are the ALARM sx’s of GERD?

A

dysphagia, odynophagia, weight loss, bleeding (suspect malignancy)

180
Q

how do you dx GERD?

A
  1. Clinical dx based on hx
  2. Endoscopy: often used 1st* if persistent sx’s or complications of GERD (ex. Malignancy, etc.)
  3. Esophageal Manometry: decr. LES pressure* - may be used if upper EGD nml
  4. 24h ambulatory pH monitoring: gold standard* - only needed if sx’s are persistent and dx uncertain
181
Q

what dx test is used first for GERD?

A

endoscopy (if persistent sx’s or complications of GERD like malignancy)

182
Q

what’s the GOLD STANDARD for dx GERD?

A

24h ambulatory pH

183
Q

what’s the tx for GERD?

A
  1. Lifestyle Mods:
    - Elevate HOB, avoid supine pos. for 3 hrs after eating, etc.
  2. PRN Pharm Tx:
    - H2-receptor antagonists (ex. ranitidine)***
    - if alarm of atypical sx’s -> upper EGD
  3. Scheduled Pharm Tx:
    - H2 blockers, PPI & pro kinetic agents (Cisapride)
    - ***PPIs = drug of choice in mod-severe disease
184
Q

when is Nissan fundoplication done for GERD?

A

if lifestyle mods and pharm tx’s are not working and pt still having sx’s

185
Q

what’s the difference b/w internal and external hemorrhoids in terms of location?

A

internal hemorrhoids = proximal to the dentate line

external hemorrhoids = distal to the dentate line

186
Q

how do you dx hemorrhoids?

A

Visual inspection

Anoscopy (esp. to see 1st degree)

187
Q

what do internal hemorrhoids look like on anoscopy?

A

bulging purple/blue veins

188
Q

what do prolapsed internal hemorrhoids look like on anoscopy?

A

dark pink, glistening, sometimes tender

189
Q

what do thromboses external hemorrhoids look like on anoscopy?

A

acutely tender, purple/blue

190
Q

what’s the tx for 1st degree hemorrhoids that are asymptomatic?

A

bulking agents (e.g. psyllium derivatives, high fiber diet, warm sitz bath)

191
Q

what’s the tx for 1st degree hemorrhoids that are symptomatic?

A

topical agents (e.g. hydrocortisone cream, lidocaine, witch hazel, zinc oxide paste)

***Bleeding: rubber band ligation or injection sclerotherapy

192
Q

what’s the tx for bleeding 1st degree hemorrhoids?

A

rubber band ligation (or injection sclerotherapy)

193
Q

what’s the tx for 2nd degree hemorrhoids?

A

Conservative management or rubber-band ligation

194
Q

what’s the tx for 3rd degree hemorrhoids?

A

rubber-band ligation; maybe surgical hemorrhoidectomy

195
Q

what’s the tx for 4th degree hemorrhoids?

A

surgical hemorrhoidectomy

196
Q

what’s the tx for external hemorrhoids if thromboses?

A

<72 hrs thrombosed excision and clot evacuation

> 72 hrs thromboses = conservative tx

197
Q

what’s the tx for external hemorrhoids?

A

conservative tx -> if fail this or interferes w/perianal hygiene (have pruritus) then excision

198
Q

what is HCC a/w?

A

cirrhosis, Hep B, and Hep C

199
Q

what’s the dominant cause of HCC?

A

Hep B

200
Q

what are RF’s for HCC?

A

NAFLD, ETOH, Hep B and C

201
Q

what’s the s/s of HCC?

A

known cirrhosis, worsening jaundice, encephalopathy, increasing ascites, weight loss, hepatosplenomegaly, abd pain

202
Q

what’s the screening like for HCC?

A

HBV testing recommended → vaccine

Cirrhosis from HBV, HCV, alcohol

US/CT/MRI and AFB q6 months

203
Q

who MUST be investigated for possible HCC?

A

Any mass >1 cm in pt w/ cirrhosis

204
Q

what are the labs to dx HCC?

A

***increased AFP (>500-1000 mg/dL)

HBsAg (pos. Hep B)

205
Q

what’s the imaging to dx HCC?

A

***U/S; MRI

CT shows localization & extent

206
Q

if pt has <1cm lesion on liver, what do you do?

A

f/u q3 months

207
Q

if pt has 1-2 cm lesion on liver, what do you do?

A

biopsy the lesion

208
Q

if pt has >2 cm lesion on liver, w/ cirrhosis, characteristic imaging findings, increased AFP, what do you do?

A

don’t bx -> has HCC

209
Q

what’s the tx for HCC?

A

surgical resection w/clear margins if confined to a lobe & not a/w cirrhosis

SURGERY = ONLY LONG-TERM CURE

210
Q

what’s the liver transplant criteria?

A

single tumor <5cm or up to 3 tumors all = 3 cms, no vascular invasion

211
Q

what’s the medical/palliative tx for HCC?

A

Sorafenib (VEGF inhibitor) → slows progression w/ advanced HCC

Large or multifocal tumor via hepatic a.

  • Chemoembolization (TACE)
  • Radioembolization (TARE)
  • Bridge to liver transplant
212
Q

who do you NOT do surgery on for HCC? what tx do they get?

A

comorbid factors, >3 lesions or any >6 cm, gross vascular invasion, mets, or LN(+)

get palliative care/medical tx

213
Q

MC malignant tumors found in the liver are from what?

A

mets!!! - MC from a GI source!!!

214
Q

what is cholangiocarcinoma?

A

Arises from mucosa of the biliary tree

Present in periphery of the liver, centrally w/in the liver, or involving the extrahepatic bile ducts

215
Q

what are the sx’s of peripheral cholangiocarcinoma tumors?

A

asx

216
Q

what are the sx’s of central/hilar cholangiocarcinoma tumors?

A

cause obstructive jaundice & a bile duct stricture on endoscopic retrograde cholangiopancreatography (ERCP)

217
Q

what’s the tx for cholangiocarcinoma?

A

liver resection

218
Q

what side of the body are indirect inguinal hernias the MC on?

A

right side

219
Q

where do indirect inguinal hernias protrude? where do they exit?

A

internal inguinal ring LATERAL to the inf. epigastric artery

go thru the internal ring into the inguinal canal and follow the testicle tract into the scrotum

220
Q

what’s the cause of indirect inguinal hernias?

A

Often congenital d/t persistent patent processus vaginalis

221
Q

who are indirect inguinal hernias MC in?

A

MC in young children & young adults

222
Q

what’s the MC type of hernia overall in men & women?

A

indirect inguinal hernias

223
Q

where do direct inguinal hernias protrude? where does it exit?

A

Protrude MEDIAL to the inferior epigastric vessels w/in Hesselbach’s triangle

can go through the superficial ring (doesn’t reach the scrotum)

224
Q

what are the borders of Hesselbach’s triangle?

A

“RIP”

Rectus Abdominis (medial)

Inferior epigastric vessels (lateral) &

Poupart’s (inguinal) ligament (inferiorly)

225
Q

what’s the cause of direct inguinal hernias?

A

d/t weakness in the floor of the inguinal canal

226
Q

what are s/s of incarcerated hernias?

A

painful, enlargement of an irreducible hernia +/- N/V if bowel obstruction present

227
Q

what are s/s of strangulated hernias?

A

ischemic* incarcerated hernias with systemic toxicity* (irreducible hernia w/ compromised blood supply)

Severe painful bowel movement (may refrain defecation)

228
Q

what are RFs of inguinal hernias?

A

delayed descent of testicles

229
Q

where does femoral hernias protrude?

A

femoral canal below the inguinal ligament

230
Q

what’s the tx for femoral hernias?

A

Often become incarcerated or strangulated compared to inguinal → surgical repair often done

231
Q

what are incisional (ventral) hernias? d/t what?

A

Herniation through weakness in the abdominal wall through previous fascial incision, usually from laparoscopy

Usu. d/t deep wound infection

232
Q

incisional (ventral) hernias are MC with what types of incisions and patients?

A

MC with vertical incisions and in obese patients

233
Q

what are RFs for incisional (ventral) hernias?

A

obesity/anything that incr. abd pressure

234
Q

what’s the tx for asx hernias?

A

observation

235
Q

what’s the palliative tx for hernias?

A

a truss

236
Q

what’s the tx for strangulated hernia?

A

manual reduction by putting pt in trendelenburg position and applying pressure to hernia

237
Q

what’s the tx for hernias if sx?

A

surgical reduction and placement of mesh to prevent reoccurrence

238
Q

what are the 4 types of hiatal hernias?

A

Type 1 = “sliding hiatal hernia”

Type 2 = “rolling hernia: (paraesophageal)

Type 3 = combo of type 1 & 2

Type 4 = herniation of other organs including the colon & spleen

239
Q

what’s the MC type of hiatal hernia?

A

Type 1 (sliding hiatal hernia)

240
Q

what is Type 1 sliding hiatal hernia a/w?

A

GERD

241
Q

what is Type 1 sliding hiatal hernia?

A

Gastroesophageal junction slides in and out of the chest (mediastinum) thru the esophageal hiatus → increases reflux

242
Q

what does Type 1 sliding hiatal hernia increase?

A

reflux

243
Q

what’s the tx for Type 1 sliding hiatal hernia?

A

Asymptomatic can be observed b/c no risk for incarceration

Surgical tx is determined by sx’s of GERD

Management similar to GERD

Surgery = fundoplication

244
Q

what’s Type 2 paraesophgeal (rolling) hiatal hernia?

A

Fundus of stomach protrude thru diaphragm w/ the GE junction remaining in its anatomic location

245
Q

what can Type 2 paraesophgeal (rolling) hiatal hernia lead to?

A

strangulation

246
Q

what’s the tx for Type 2 paraesophgeal (rolling) hiatal hernia?

A

Surgical repair of the defect to avoid complications such as strangulation and ischemia

247
Q

what’s the difference b/w Type 1 sliding hiatal hernia and Type 2 rolling paraesophageal hiatal hernia?

A

in sliding hiatal hernia, the stomach remains in its position (vs paraesophageal it doesn’t b/c the funds protrude thru the diaphragm)

248
Q

what remains in place in paraesophageal hernia?

A

GE junction

249
Q

what areas are affected in Crohn’s disease?

A

ANY SEGMENT OF THE GIT from MOUTH TO ANUS

MC site is the TERMINAL ILEUM -> RLQ PAIN

250
Q

how much of the colon is affected in Crohn’s disease?

A

TRANSMURAL INFLAMMATORY

251
Q

what type of lesions are seen in Crohn’s disease?

A

skip lesions with cobblestone appearance

252
Q

what are complications a/w Crohn’s disease?

A

Perianal dz: fistulas, strictures, abscess, NONCASEATING GRANULOMAS

Malabsorption: Fe & B12 deficiency

253
Q

what’s the s/s of Crohn’s disease?

A

Abd pain: RLQ pain MC (kramp) & weight loss

Diarrhea with NO VISIBLE BLOOD

Perianal involvement (fistulae, fissures, abscesses)

Extra-intestinal manifestations

254
Q

what are the nutritional losses with Crohn’s disease?

A

hypoalbuminemia, fat soluble vit (A, D, E, K) def., and vit B12 def (b/c affect terminal ileum)

d/t diminished PO intake and impaired absorption

255
Q

what does barium study show for Crohn’s?

A

String sign -> barium flow through narrowed inflamed/scarred area d/t transmural strictures

256
Q

what lab is positive in Crohn’s disease?

A

+ ASCA

257
Q

is surgery curative for Crohn’s or UC?

A

surgery is curative for UC, but NOT curative Crohn’s

258
Q

what’s the imaging test of choice for dx of Crohn’s? what are the findings on it?

A

colonoscopy w/ bx (gold standard for dx)

-findings are aphthoid, stellate, linear ulcers

259
Q

what are Crohn’s patients counseled to quit?

A

smoking

260
Q

what’s the tx for Crohn’s for mild disease and for maintenance of disease?

A

5-ASA (Mesalamine - preferred for maintenance; Sulfasalazine)

-released in the terminal ileum and ascending colon

261
Q

what’s the tx for Crohn’s for flares?

A

Corticosteroids (esp. when unresponsive to sulfasalazine/mesalamine)

-Budesonide (greatest effect on terminal ileum & R-sided colonic disease)

262
Q

when are immunosuppressants used for Crohn’s and what are they?

A

good for pts unresponsive to steroids or to minimize steroid use

  • Azathioprine/6-MP (3-6 months to achieve effect)
  • Methotrexate (remission sustaining)
  • Cyclosporine (used in fistulous Crohn’s unresponsive to steroids & abx)
263
Q

when is Cyclosporine used in Crohn’s? wha are you concerned about with it?

A

used in fistulous Crohn’s unresponsive to steroids & abx

concern for nephrotoxicity and need ppx for Pneumocystis carinii pneumonitis

264
Q

what do the immunosuppressants prevent in Crohn’s?

A

relapse of disease once in remission

265
Q

when are TNF alpha-blockers (anti-biologics) used for Crohn’s? what are the names?

A

if steroid-resistant, mod-severe Crohn’s

Infliximab, Adalimumab, Certolizumab, Natalizumab

266
Q

when is surgery indicated for Crohn’s? is it curative for Crohn’s?

A

Reserved for complicated disease and disease refractory to medical management

Perforation, fistulae, obstruction (fibrotic stricture)

***SURGERY IS NOT CURATIVE

267
Q

what are complications of surgery in Crohn’s?

A

short bowel syndrome d/t resection in surgery

268
Q

who is UC most common in?

A

Jews and family hx

269
Q

what areas are affected in UC?

A

LIMITED TO COLON
-mucosa and submucosa of the large bowel and rectum

ALWAYS INVOLVES THE RECTUM (begins in rectum and spreads proximally to colon)

270
Q

what is seen on colonoscopy for UC?

A

uniform inflammation - friable, reddish mucosa w/no skip areas, mucosal exudate, and PSEUDOPOLYPS

271
Q

what are the s/s of UC?

A

abdominal pain: LLQ MC,* colicky

Tenesmus,* urgency

BLOODY DIARRHEA = HALLMARK (stools w/mucus/pus), hematochezia

also, extra intestinal sx’s (ankylosing spondylitis, peripheral arthritis, uveitis, sclerosing cholangitis)

272
Q

what’s the HALLMARK sx of UC?

A

BLOODY DIARRHEA W/PUS AND MUCUS

273
Q

how do you dx UC?

A

Colonoscopy w/ bx (gold standard) - friable, reddish mucosa w/no skip areas, mucosal exudate, and pseudo polyps

serologic markers -> pANCA

barium study (2nd line)

274
Q

what are complications of UC?

A

primary sclerosing cholangitis, colon cancer, toxic megacolon (MC in UC)

275
Q

what is seen on the barium study for UC?

A

“stovepipe sign” (loss of haustral markings)

276
Q

what’s the tx for mild UC?

A

symptomatic tx, with antidiarrheal agents that slow gut transit (e.g. loperamide) and bulking agents (e.g. psyllium)

277
Q

what’s the tx for mod. UC?

A

Sulfasalazine or mesalamine → induce remission

278
Q

what’s the tx for severe UC?

A

steroid taper (d/t adrs)

279
Q

what’s the maintenance tx for UC?

A

PO mesalamine or sulfasalazine for maintenance and budesonide for flares

280
Q

when is surgery indicated for UC?

A

indicated when medical therapy fails or surgically treatable complications occur (e.g., hemorrhage, perforation, obstruction, dysplasia, carcinoma)

long-standing UC is an indication for surgery b/c of increased risk of carcinoma

281
Q

what do people with LONG-STANDING UC have an increased risk of?

A

increased risk of carcinoma

282
Q

what’s the surgery of choice for UC?

A

Total colectomy w/ proctectomy and ileoanal pull-through

283
Q

at what levels of bilirubin does jaundice occur?

A

> 2.5 mg/dL

284
Q

increased direct (conjugated) bilirubin causes what symptoms?

A

dark urine & light-colored stools

285
Q

what are causes of jaundice?

A

hemolytic (incr. bilirubin overproduction)

hepatocellular (e.g. hepatitis) - der. hepatic bilirubin uptake, impaired conjugation

Obstructive (biliary obstruction)

286
Q

increased bilirubin w/out increased LFTs, what should you suspect?

A

familial bilirubin d/o’s (Dubin-Johnson Syndrome, Gilbert Syndrome) & hemolysis

287
Q

what is elevated in hemolytic jaundice? dx?

A

Low level (bilirubin of 6 or 8), and all the elevated bilirubin is unconjugated (indirect), no elevation of the direct

no bile in urine

dx: work-up to determine what is causing hemolysis

288
Q

what is elevated in obstructive jaundice?

A

Elevations of both fractions of bilirubin

Modest elevation of AST/ALT
Very high ALP

289
Q

what’s the first step in the dx of obstructive jaundice?

A

sonogram (looking for dilatation of the biliary ducts and other clues of cause of obstruction)

290
Q

what is elevated in hepatocellular jaundice?

A

Elevation of both fractions of bilirubin and very high levels of AST/ALT

Modest elevation of the ALP

291
Q

what’s the MC cause of hepatocellular jaundice?

A

Hepatitis

292
Q

what’s the MC histology of pancreatic cancer?

A

adenocarcinoma - ductal MC

293
Q

where is the MC place for pancreatic cancer to occur in the pancreas?

A

the head of the pancreas

294
Q

what are the RFs for pancreatic cancer?

A

**smoking, **>60 y/o (doubles risk), ***fam hx (>2 1st degree relatives)

chronic pancreatitis, ETOH, DM, males, obesity, AA

295
Q

what is the MC genetic mutation a/w pancreatic cancer?

A

K-ras oncogene

296
Q

what are the s/s of pancreatic cancer?

A

Usu. have mets by time of presentation (to LNs and liver)

Painless jaundice* classic → 2/2 CBD obstruction

Weight loss, CONSTANT abd pain → back (may be relieved w/ sitting up & leaning forward)

Pruritus (d/t incr. bile salts in skin)

297
Q

what is Trousseau’s malignancy sign?

A

migratory phlebitis a/w malignancy

298
Q

what are PE signs for pancreatic carcinoma?

A

Courvoisier’s sign* = palpable, NON-tender, distended, gallbladder* a/w jaundice (CBD obstruction)

299
Q

what are labs like for pancreatic carcinoma?

A

increased tumor markers: CEA, **CA 19-9

300
Q

what’s the initial imaging study for pancreatic carcinoma? what’s the most sensitive?

A

CT scan = initial dx test of choice

ERCP = most sensitive test

301
Q

what’s the surgery for pancreatic cancer head tumors?

A

Whipple procedure = pancreaticoduodenectomy resection

-Resection of distal CBD, duodenum, and head of pancreas

302
Q

what’s the surgery for pancreatic cancer body & distal tumors?

A

distal pancreatectomy (includes a splenectomy)

303
Q

what’s the tx for advanced or inoperative pancreatic cancer?

A

ERCP w/ stent placement as palliative tx for intractable itching

304
Q

what’s the prognosis like for pancreatic cancer?

A

very poor, most lesions unresectable

305
Q

what is the MC complication of pancreatitis?

A

pancreatic pseudocyst

306
Q

what is pancreatic pseudocyst? caused by what?

A

Development of fluid in the peripancreatic area or retroperitoneum

Caused by disruption of the pancreatic duct → enzymatic fluid collects around the pancreas and is walled-off by surrounding viscera

Most acute fluid collections resolve spontaneously, but those that persist become pseudocysts

307
Q

what can pancreatic pseudocysts become?

A

communicating or non-communicating, based upon whether the cyst is connected to the pancreatic duct

308
Q

what are the s/s of pancreatic pseudocysts?

A

Occur when pseudocysts grow large
Epigastric pain, N/V, early satiety

Most sx’s related to compression of adjacent structures including mechanical obstruction of stomach, duodenum, or CBD

309
Q

how do you dx pancreatic pseudocysts?

A

CT - show cyst walls and their relation to surrounding structures

310
Q

what’s the tx of pancreatic pseudocyst of non-communicating with pancreatic duct?

A

Aspirated or drained percutaneously

311
Q

what’s the tx of pancreatic pseudocyst of communicating with pancreatic duct??

A

Internal drainage into the stomach, duodenum, or Roux limb to prevent formation of a pancreatic fistula, since they directly communicate w/ the pancreatic duct

Goal is to avoid fluid draining back into the pancreas to prevent formation of pancreatic fistula

312
Q

what is PUD d/t?

A

2/2 imbalance of decr. mucosal protective factors in gastric ulcer & incr. damaging factors (acid, pepsin) in duodenal ulcer

313
Q

what are the MC type of peptic ulcers? where do they form?

A

duodenal ulcers

-form in duodenal bulb

314
Q

what’s the MC cause of PUD?

A

H. pylori

315
Q

what’s the 2nd MC cause of PUD?

A

NSAIDs

316
Q

what are the 2 MC causes of PUD?

A

H. pylori - 1st MC

NSAIDs - 2nd MC

317
Q

what are other causes of PUD besides H. pylori and NSAIDs/

A

Zollinger-Ellison syndrome (gastrin producing tumor)

ETOH, smoking, stress, et.c

318
Q

when should you suspect GI malignancy like ZES or gastric cancer in a/w a gastric ulcer?

A

in non-healing gastric ulcer

319
Q

what are the s/s of PUD?

A
  1. Dyspepsia (epigastric pain that’s burning)

2. UGIB (PUD = MC cause of UGIB)

320
Q

what’s the MC cause of UGIB?

A

PUD

321
Q

when is the dyspepsia in PUD worse, at night or in the morning?

A

worse at night

322
Q

what are duodenal ulcer s/s like? what pts are they the MC in?

A

Relief w/ food, antacids &/or anti-secretory agents

Worse before meals or 2-5 hrs after meals

Nocturnal sx’s = classic

Younger patients MC

323
Q

what are gastric ulcer s/s like?

A

Pain 1-2 hrs after meals & weight loss (b/c pain a/w w/food)

Older patients MC

324
Q

which ulcers are relieved with food, duodenal or gastric?

A

duodenal ulcers

325
Q

what ulcers are worse before meals or 2-5 hrs after meals?

A

duodenal ulcers

326
Q

what sx’s are classic of duodenal ulcers?

A

nocturnal sx’s

327
Q

what ulcers are food-provoked?

A

gastric ulcers

328
Q

what ulcers are worse 1-2 hrs after meals and weight loss?

A

gastric ulcers (b/c pain a/w with food)

329
Q

what’s the GOLD STANDARD to dx PUD?

A

Endoscopy (bx to r/o malignancy if GU present and if alarm sx’s)

330
Q

when is barium upper GI series used to dx PUD?

A

in pts unable to do EGD

331
Q

what’s the dx tests for PUD?

A

Endoscopy (w/ bx if have GU or H. pylori)

Barium Upper GI series (in pts unable to do EGD)

332
Q

what must GU ulcer be dx with?

A

endoscopy w/ bx

333
Q

what’s the GOLD STANDARD to dx H. Pylori?

A

EGD w/ bx

334
Q

what’s the dx tests for H. Pylori (cause of PUD)?

A

EGD w/ bx = GOLD STANDARD***
- + rapid urease test: direct stain of bx for H. pylori

    • Urea breath test: (used for testing if EGD can’t be done, but can also be used to confirm eradication after therapy)
    • H. Pylori stool antigen (HpSA): >90% specific
      - Useful for dx H. pylori & confirming eradication after therapy
    • Serologic antibodies: only useful in confirming H. pylori infection (NOT eradication)!*
335
Q

what tests for H. pylori are useful to confirm eradication after tx?

A

Urea breath test and H. pylori stool antigen (HpSA)

336
Q

when is urea breath test used to dx H. Pylori?

A

if EGD can’t be done, also to confirm eradication after therapy

337
Q

what H. pylori test is >90% specific and useful for dx of H. pylori and confirming eradication after tx?

A

H. Pylori stool antigen (HpSA)

338
Q

what H. pylori test is NOT for eradication and only for confirmation of H. pylori infection?

A

Serologic antibodies

339
Q

what’s the triple therapy for H. Pylori tx?

A

Clarithromycin + Amox + PPI* (CAP)

Metro if PCN allergic

340
Q

what’s the quadruple therapy for H. Pylori tx?

A

PPI + Bismuth subsalicylate + Tetracycline + Metronidazole

341
Q

what’s the tx for PUD if H. pylori is NOT the cause?

A

PPI (drug of choice) - most effective drug to treat PUD
-take 30 min before meals

H2 blocker, Misoprostal, antacids, bismuth subsalicylate, sucralfate

342
Q

what is the drug of choice to treat PUD if H. pylori is NOT the cause? when do you take it?

A

PPI - take 30 min before meals

343
Q

what’s adr can you get from PPIs?

A

B12 deficiency

344
Q

what are causes of Small bowel carcinoma?

A

Adenocarcinoma, Carcinoid tumors, Lymphoma, GI stromal tumors

345
Q

what’s the MC small bowel tumor? where is it found?

A

adenocarcinoma - usu. found in the duodenum

346
Q

where do carcinoid tumors arise from?

A

Kulchitsky cells in the crypts of Lieberkuhn

347
Q

where is carcinoid tumors the MC?

A

in the ileum

348
Q

what’s the MC site of extranodal lymphoma?

A

small bowel - int he ileum

349
Q

what are GI stroll tumors? where are they found? what do they respond well to?

A

Mesenchymal tumors of the GIT

Found anywhere in the small bowel

Poor prognosis, but responds well to tyrosine kinase inhibitors

350
Q

what are the s/s of small bowel carcinoma?

A

obstruction sx’s (MC)

anorexia, fatigue, weight loss

351
Q

how do you dx small bowel carcinoma?

A

Laparotomy, enteroclysis, capsule endoscopy, or Ct enterography

352
Q

what’s the tx for small bowel carcinoma?

A

Colectomy/surgical resection of tumor

353
Q

what is toxic megaton?

A

Non-obstructive, extreme colon dilation >6cm + signs of systemic toxicity*

354
Q

what are causes of toxic megacolon?

A

UC, Crohn’s, pseudomembranous colitis, infectious, radiation, ischemic

355
Q

what are s/s of toxic megacolon?

A

Fever, abd pain, diarrhea, N/V, rectal bleeding, tenesmus, electrolyte d/o’s

356
Q

what’s the PE like for toxic megacolon?

A

Abd tenderness, rigidity, tachycardia, dehydration, hypotension, AMS

357
Q

how do you dx toxic megacolon?

A

Abd radiographs: large dilated colon >6cm

358
Q

what’s the tx for toxic megacolon?

A

Bowel decompression

Bowel rest, NG tube, abx

Electrolyte repletion

Colostomy for refractory cases

359
Q

how do you dx gastritis?

A

endoscopy

360
Q

what are the sx’s of gastritis if symptomatic?

A

epigastric pain

361
Q

what is celiac disease?

A

small bowel AUTOIMMUNE inflammation 2/2 alpha-gliadin in GLUTEN -> loss of villi & absorptive area -> impaired fat absorption

362
Q

who is at increased risk of celiac disease?

A

females, European descent (Irish & Finnish)

363
Q

what are the s/s of celiac disease?

A

malabsorption: diarrhea

Dermatitis herpetiformis (pruritic, paplovesicular rash on extensor surfaces, neck, trunk, & scalp)

364
Q

how do you dx celiac disease?

A

+ Endomysial IgA antibiody & transglutaminase antibody

Small bowel bx = definitive dx

365
Q

how do you definitively dx celiac disease?

A

small bowel bx

366
Q

what’s the test of choice for lactose intolerance?

A

hydrogen breath test (performed after a trial of lactose free diet)

367
Q

what’s type of diet is a RF for small bowel carcinoma?

A

***diet high in salt-cured foods

diet high in refined sugar, red meat, and smoked foods

ETOH use

368
Q

what d/o’s are RF for small bowel carcinoma?

A

FAP, Lynch, Peutz-Jeghers syndromes, IBD

369
Q

how do you dx UGIB?

A

endoscopy

370
Q

when does screening for colorectal cancer begin for average-risk pts and when does it end? when do you stop screening?

A

at 50 y/o and ends at 75 y/o

Stop screening when pts lifespan is < 10 years

371
Q

when does screening for colorectal cancer begin for high-risk pts?

A

40 y/o (<50 y/o)

372
Q

what are the indications to do EGD for pt with dyspnea?

A

< 60 y/o if:
-clinically significant weight loss, alarm sx’s, overt GI bleeding (ex. melena), >/= 1 alarm sx’s present

all pts >/= 60 y/o with new dyspepsia

373
Q

what are the sx’s of a strangulated hernia? what’s the tx?

A

tenderness, pain, bd distention, N/V, erythema over hernia site, fever, peritonitis

tx: surgery (surgical emergency)

374
Q

what test do you run to establish dx of jaundice?

A

fractionated bilirubin

375
Q

when is watchful waiting an option for Crohn’s disease?

A

if asx and found to have CD incidentally on routine colonoscopy

376
Q

what’s the best long-term tx for chronic pilonidal disease?

A

surgical excision of all sinus tracts

377
Q

what’s the MC post-surgical complication by pts undergoing surgery tx for PUD?

A

weight loss

378
Q

what med is administered to pt undergoing unilateral/bilateral adrenalectomy and why?

A

IV hydrocortisone (glucocorticoid) to prevent hypotension

379
Q

what’s the MOST IMPORTANT FIRST step in tx for GI bleed? what’s done next?

A

IV access = first step

NGT is done next

380
Q

what imaging study is done to assess disease extent and respectability of pancreatic cancer?

A

Abd CT w/ contrast

381
Q

what’s the BEST approach for adrenalectomy when malignancy is suspected/

A

open trans abdominal approach -> allows more visualization

382
Q

if doing bilateral adrenalectomy, what’s the best approach?

A

posterior retroperitoneoscopic

383
Q

how do you dx colonic polyps?

A

colonoscopy (can also remove them)

384
Q

what are s/s of colon polyps?

A

typically asymptomatic, GI bleeding, intestinal obstruction

BRBPR, rectal tenesmus, change in bowel habits

385
Q

what are non-neoplastic colonic polyps?

A

mucosal, inflammatory, pseudopolyps, hyperplastic, submucosal, hamartomas

386
Q

what are mucosal colonic polyps?

A

small <5mm, resemble adjacent tissue

histologically normal, no clinical significance

387
Q

what are inflammatory pseudopolyps?

A

common in IBD, not malignant

388
Q

what are Hyperplastic colonic polyps?

A

MOST COMMON NON-NEOPLASTIC COLONIC POLYPS

low risk for malignancy

serrated/sawtooth pattern

most found in rectosigmoid and <5mm

389
Q

what are the MOST COMMON non-neoplastic colonic polyps?

A

Hyperplastic colonic polyps

390
Q

what are Hamartomas colonic polyps?

A

Grow in disorganized fashion

seen in FAP - juvenile polyps & Peutz-Jeghers syndrome

low malignancy, often spontaneously regress/auto-amputate; observe

391
Q

what are Neoplastic colonic polyps?

A

adenomatous polyps

392
Q

what are adenomatous polyps?

A

tumors overtime that may become malignant -> 7-10 yrs avg time to transition to adenocarcinoma

personal hx of colon adenomas increases risk of CRC

393
Q

what are the 3 types of Adenomatous colonic polyps?

A

Tubular adenoma: nonpedunculated (MC & least risk of malignancy of the 3 types of adenomatous polyps)

Tubulovillous (mixture) adenoma: intermediate risk of malignancy - pedunculated

Villous adenoma: highest risk of becoming cancerous - sessile

394
Q

what is the tx of colonic polyps?

A

Polypectomy

395
Q

when should IBD pts tha have had IBD for >/= 10 years have colonoscopy?

A

every year colonscopic surveillance w/ bx

396
Q

how often is flexible sigmoidoscopy done?

A

every 5 years

397
Q

how often is conoscopy done

A

every 10 years

398
Q

how often is double-contrast barium enema done?

A

every 5 years

399
Q

how often is FOBT done for colonic polyp screening?

A

every year

400
Q

how often is FIT done for polyp screening?

A

every year

401
Q

what pts are at high risk of developing colorectal cancer?

A

those with familial colorectal cancer syndromes and pts who’ve had IBD for >/= 10 years

402
Q

what’s the most important risk for colorectal cancer?

A

family h/o in 1st degree relatives

403
Q

what lab value indicates pancreatic cancer?

A

CA 19-9

404
Q

what is achalasia?

A

loss of Auerbach’s plexus -> INCREASED LES PRESSURE***

405
Q

what is the pathophysiology of achalasia?

A

failure of LES relaxation (increased LES tone) -> obstruction and lack of peristalsis

406
Q

what are the s/s of achalasia?

A

dysphagia to BOTH solids and liquids

407
Q

what’s the GOLD STANDARD to dx achalasia? what does it show?

A

esophageal manometry

shows increased LES pressure >40 mmHg

408
Q

what do you see on double-contrast esophageal with achalasia?

A

bird’s beak appearance of LES (LES narrowing)

409
Q

what’s the treatment for achalasia?

A

decrease LES pressure -> botox, nitrates, CCBs

410
Q

what tumor marker is used to monitor recurrence of colon cancer?

A

CEA

411
Q

what medication is used to control acute variceal bleeding?

A

octreotide

412
Q

what treatment decreases the risk of rebreeding in a pt with esophageal varices?

A

Sclerotherapy

413
Q

what are the s/s of anal fissures?

A

Pain increased during BMs & a/w streaks of blood in stool (bright red)

414
Q

what’s the MC RF for esophageal varices in adults?

A

cirrhosis

415
Q

what’s the s/s of esophageal varices?

A

UGIB (hematemesis, melena)

416
Q

how do you dx esophageal varices?

A

upper endoscopy -> enlarged veins

417
Q

what’s the tx for management of acute active bleeding varices?

A
  1. stabilize with 2 large bore IV lines, IVFs
  2. Endoscopic ligation = TOC
  3. Octreotide = med of choice in acute bleeding or vasopressin
418
Q

when do you use saloon tamponade to control active bleeding varices?

A

to stabilize bleeding NOT controlled by endoscopic or pharmacologic intervention

419
Q

when do you use TIPS for active bleeding varices?

A

if bleeding despite endoscopic or pharmacologic tx

420
Q

what’s the TOC for active bleeding varices?

A

endoscopic ligation

421
Q

what’s the tx to prevent rebreeds of varices?

A
  1. Non-selective beta blockers -> TOC in primary ppx to prevent rebleed (propranolol, nadolol)
  2. Isosorbide -> long acting nitrate (vasodilator)

NOT GIVEN IN ACUTE BLEEDS

422
Q

what’s the TOC for ppx of rebleeding varices?

A

non-selective BBs -> propranolol, nadolol

423
Q

what is boerhaave syndrome?

A

full thickness rupture of the DISTAL esophagus that’s a/w repeated, forceful vomiting

424
Q

what’s the s/s of boerhaave syndrome?

A

retrosternal chest pain rose with deep breathing and swallowing

425
Q

what’s the PE like for boerhaave syndrome?

A

crepitus on chest auscultation d/t PNEUMOMEDIASTINUM (air in the mediastinum) -> see on CXR or chest CT

426
Q

what’s the definitive dx for boerhaave syndrome?

A

contrast esophageal with gastrografin swallow

427
Q

what’s mallory-weiss syndrome?

A

UGIB from LONGITUDINAL MUCOSAL lacerations at the GE junction or the gastric cardia (occurs in submucosal layer)

428
Q

how do you dx mallory-weiss syndrome?

A

upper endoscopy = TOC -> see SUPERFICIAL LONGITUDINAL MUCOSAL EROSIONS

429
Q

what’s the tx for mallory-weiss syndrome?

A
  1. Supportive (most cases stop w/out tx)

2. if severe bleeding -> epinephrine injection

Surgery Rotation EORE (10 decks)

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