GI 2 Flashcards
Management of aspirin following endoscopy for bleeding ulcer and treatment of ulcer
Resume within 1 to 7 days + start PPI
Vaccines contraindicated for immunocompromised patients
live attenuated –
1) **Varicella
2) yellow fever
- live attenuated zoster
- MMR
- BCG
Diagnostic criteria for eosinophilic esophagitis
1) dysphagia
2) esophageal biopsies showing 15 eosinophils per high powered field
3) exclusion of other causes of esophageal eosinophilic
NASH diagnosis
Elevated liver chemistries + negative workup for other causes + evidence of metabolic syndrome + characteristic abdominal imaging
Screening threshold for hemochromatosis
Transferrin saturation greater than 45%
PBC clinical features
- middle aged woman
- pruritus, fatigue
PBC lab features
- elevated ALP
Workup of PBC appearing patient with negative anti-mitochondrial antibody
sp100 and gp210 antibodies
Antibody positive in PBC
Antimitochondrial antibody
Treatment of mild to moderate left-sided ulcerative colitis
Combined mesalamine therapy (oral and topical)
Distribution categories of ulcerative colitis
- proctitis (rectal involvement only)
- left sided colitis (doesn’t extend beyond the splenic flexure)
- pan colitis (extends above splenic flexure)
Treatment of moderate to severe flares of IBD
oral and IV steroids
Presentation of Hep B-related polyarteritis nodosa
Fever, arthralgia, cutaneous vasculitis (looks like cryoglobulinemia) + evidence of active hep b
First step in evaluation of dyspepsia
- test for h pylori (can’t start PPI without testing for h pylori first)
Management of achalasia
IF low surgical risk – endoscopic pneumatic dilation
IF high surgical risk – botox injections
*medical therapy is third line
Specificity of crypt abscesses and colonic crypts
- nonspecific, found in both Crohn’s and UC
Indications for HBV treatment
1) Elevated aminotransferase levels
2) all cirrhotics
3) undergoing treatment with certain immunosuppressive or chemo regimens
When patients with HBV need HCC screening
- Southeast Asians patients at age 40
- Patients from sub-saharan Africa at age 20
- persistently elevated liver enzymes
- FH of HCC
- Patients with above indications need screening even absent
First step in management of suspected overflow fecal incontinence
KUB
Cause of GI bleed following aortic graft surgery
Aortoenteric fistula (communication between aorta and GI tract
Workup of suspected aortoenteric fistula
CT with contrast
Autoimmune hepatitis diagnosis
- required biopsy
- can’t diagnose base on anti-smooth muscle antibody test
Indications for 5 year follow-up after c-scope
- 2 or fewer adenomas (or sessile serrated polyps)
- 1st degree relative with CRC diagnosed at an age younger than 60
Indications for 3 year follow-up after c-scope
- 3 or more adenomas
- 1 adenoma larger than 10 mm
- adenoma with any degree of villous or high-grade dysplasia
Management of chronic constipation unresponsive to first line treatment
linaclotide
Indications for prophylactic abx in cirrhotics with ascites
High risk of SBP:
- very low ascitic fluid protein levels (less than 1.5g/dl)
- advanced liver failure
Syndrome that presents similarly to celiac’s
- medication-induced enteropathy
Med that is common culprit of medication-induced enteropathy
Olmesartan
When CRC screening needs to be performed in patient with family member with CRC
- Age 40 or 10 years earlier than the youngest age
High risk categories for CRC
- first degree relative with colon cancer diagnosed younger than 60
- 2 or more relatives with CRC at any age
Repeat interval if initial c-scope normal in high risk individual
5 years if first-degree relative younger than 60
- 10 years otherwise
Evaluation of persistent GERD + why
- ambulatory pH testing (extra esophageal symptoms like cough/asthma/globus/hoarseness can be due to laryngopharyngeal reflux so need to exclude this)
Treatment of amebic liver abscess
Metronidazole + paromomycin
Microscopic colitis diagnosis
- colonoscopy with random biopsies from multiple segments
Microscopic colitis clinical features + biopsy findings
- chronic, watery diarrhea in an old person + abdominal pain + weight loss + arthralgias
- biopsy = lymphocyte-predominant mononuclear lymphocytic infiltrates + focal cryptitis
SIBO clinical features
- malabsorption symptoms bloating, flatulance, weight loss
SIBO vs. microscopic colitis
microscopic colitis = isolated watery diarrhea
SIBO = malabsorption syndromes
other reasons to treat HBV
- pregnant with viral load over 200k
- acute liver failure
- nephropathy, PAN, or cryoglobulinemia
Go to for HBV treatment
Tenofovir or entecavir
management of chronic hep c
- evaluate for fibrosis/cirrhosis
- treat
- confirm cure at 12 weeks post treatment by checking RNA level
treatment of acute liver failure
- NAC (regardless of etiology)
- transplant
other workup of PBC
monitor for autoimmune thyroid disease
Next step after diagnosis of PSC
colonoscopy
Chronic management of PSC
serial US + CA19-9
Portal HTN etiologies
1) intrinsic liver disease
2) cardiac
Cutoff for SAAG indicating portal HTN
Greater than 1.1
Etiologies of SAAG less than 1.1
- malignancy
- nephrotic syndrome
- TB
management of HE
- avoid sedating medications
- lactulose
- rifaximin if no resolution with lactulose
US frequency for HCC screening in cirrhotics
q6 months
oropharyngeal dysphagia clinical features
coughing, choking with swallowing, aspiration
esophageal dysphagia
goes down okay then gets stuck
pills that cause odynophagia
doxy
ferrous sulfate
potassium
Management of esophageal dysphagia if EGD WNL
Manometry
Corkscrew on esophagram
Nutcracker or jackhammer esophagus
when to perform EGD with dyspepsia (alarm symptoms)
- weight loss
- IDA, melena
- dysphagia
- persistent vomiting
Management of dyspepsia if no improvement with PPI
TCA
Diagnosis of dumping syndrome
Oral glucose challenge test
dumping syndrome treatment
small frequent meals
next step after CT of pancreatic cancer
EUS
Initial management of pancreatic cyst
EUS (for characterization) with FNA
feature of osmotic diarrhea
worse after eating
feature of secretory diarrhea
occurs despite fasting
walking up at night with diarrhea?
inflammatory or secretory
celiac diagnosis
- serology now sufficient (Don’t need endoscopy anymore)
Celiac patients are at risk for what else (in addition to IDA)?
- GI lymphoma + microscopic colitis
Treatment of microscopic colitis
- antidiarrheals (loperamide)
- review meds, stop NSAIDS, PPI, and SSRI
IF refractory – budesonide
what to do before starting azathioprine or 6-mercaptopurine
- check TPMT (enzyme deficiency of which will cause toxicity)
- monitor for leukopenia and T cell lymphoma
C-scope interval for IBD patients
8 years after diagnosis then annually
Chronic maintenance for IBD patients
1) smoking cessation (higher risk of CRC)
2) annual PAP (higher risk for cervical cancer)
3) c-scopes
4) increased risk for osteoporosis
Lynch syndrome management
1) c-scope at 20 then annually
2) egd at 30 then q2 years
3) hysterectomy and salphingo oophorectomy at 40
When to start EGD screening for FAP patients
age 25
choledocholithiasis clinical features
abnormal LFTs + RUQ pain
choledocholithiasis other management
cholecystectomy before discharge
PPI management of clots
IF high risk stigmata (clot visible vessel, red spot) – need high dose PPI for 72 hours
initial test of choice in LGIB patient with unstable bleed
CTA (without prep or if bleeding, won’t be able to see anything with scope)
SAAG calculation
Serum albumin - ascites albumin
Indications for SBP ppx
1) cirrhosis + GI bleed
2) hx of SBP
3) hypoalbuminemia (ascitic fluid protein less than 1.5 g/L)
* should not be used for all cirrhotic patients because indiscriminate use is associated with abx resistance.
Triple therapy for HP
- clarithromycin
- amoxicillin
- PPI
Quadruple therapy for HP
- bismuth
- flagyl
- tetracyline
- PPI
dieulafoy lesion clinical features
- located in proximal stomach near esophagogastric junction
hep b and incidence of chronic hep b after acute infection
- few people develop chronic hep B but 90% of newborns develop chronic hep b
Hep B serology with acute infection
HBsAg -- + Anti-HBs -- - Anti-HBc -- + (IgM) HBeAg -- + Anti-HBe -- - *Only IgM to anti-HBc is positive among immunoglobulins, anti-HBs antibody only exists when immunized or infection resolves
Hep B serology with inactive chronic hep b
HBsAg -- + Anti-HBs -- - Anti-HBc -- + (IgG) HBeAg -- - Anti-HBe -- +
Hep B serology with immune active chronic hep b
HBsAg -- + Anti-HBs -- - Anti-HBc -- + (IgG) HBeAg -- + Anti-HBe -- -
Other indications for treating hep B
- pregnancy with viral load over 200K
- nephropathy, PAN, or cyroglobulinemia
Treatment of hep B
Tenofovir
or
Entecavir
Alcoholic hepatitis management
1) Calculate Maddrey Discriminant Function score
2) If steroids started, calculate Lille score at 7 days to determine response to treatment
When to start steroids for alcoholic hepatitis
Maddrey discriminant function score greater than 32
Management of NAFLD and NASH
Treat underlying HTN, HLD, and DM2
Sequelae of PSC
Increased risk for cholangiocarcinoma and gallbladder cancer
maintenance management of PSC
q6 month Ca 19-9 and US or MRCP
portal HTN from SAAG differential
Cardiac disease or cirrhosis
Interval for HCC screening in cirrhosis
q6 months
Treatment of nutcracker esophagus
CCB or PDEi
Corkscrew on esophagram think
nutcracker or jackhammer esophagus
Treatment of functional dyspepsia if in improvement with PPI
TCA
Complications of gastric surgery
1) Dumping syndrome
2) Increased risk for malignancy in gastric remnant
Diagnosis of gastric dumping syndrome
Oral glucose challenge test
Next step after CT or MRI suggesting pancreatic cancer
- endoscopic US to determine extent and obtain tissue diagnosis
Biomarkers of pancreatic cysts
high amylase = pseudocyst
high CEA = mucinous cyst
Diagnosis of malabsorptive diarrhea in chronic diarrhea
72hr fecal fat
Management of suspected choledocholithiasis if US is negative
MRCP
Evidence for PPI’s with UGIB
Decreases likelihood of high-risk stigmata at endoscopy, but haven’t been shown to change outcomes
Next step after lesion noted on capsule endoscopy in the small bowel
balloon enteroscopy
Boerhaave syndrome clinical features
Violent retching that leads to transmural usually distal esophageal wall rupture with pneumomediastinum
Boerhaave syndrome treatment
surgical emergency
PSC treatment
IF stricture –> tenting
IF recurrent cholangitis –> long term abx
IF advanced liver disease –> transplant
How to differentiate cardiac from liver ascites on SAAG
IF total protein greater than 2.5 – cardiac
IF less than 2.5 – liver
*basically low total protein = cirrhosis
What is nutcracker esophagus? treatment?
- motility abnormality of esophagus
- thus diagnosed by esophageal motility study
- treatment = CCB’s
Screening modality for HCC in cirrhosis
- US q6months + AFP or US q6 months
* Never AFP alone
UC vs. Crohn’s in terms of location and clinical features
- UC = confined to colon. UC can occur anywhere in GI tract
- clinical features = fistulas and perianal disease more common in Crohn’s
Pathologic features differentiating UC from Crohn’s
Crohn’s = transmural mucosal inflammation, fissures and skip lesions, granulomas
management of persistent microscopic colitis
budesonide
initial management of microscopic colitis
- discontinue triggers (smoking, meds – NSAIDS, PPIs, SSRIs, ranitidine)
- antidiarrheal meds
Treatment of moderate to severe IBS
TCA’s (amitryptiline)
Basic presentation of IBS
chronic abdominal pain + altered bowel habits
