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Internal Medicine > GI > Flashcards

GI Flashcards

1
Q

What is the best test for PSC?

TX?

A

ERCP

Liver Transplant.
Stenting can be used to reduce jaundice and cholangitis.

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2
Q

What are the risk factors of PSC

A

Ulcerative Colitis

Male

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3
Q

What is seen on ERCP for PSC

A

“beads on a string”

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4
Q

What is the treatment for PBC?

A

Ursodeoxycholic Acid

Second line: Corticosteroids, Colchine, methotrexate

Curative: Liver transplantation

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5
Q

What is PBC?

A

Autoimmune disease resulting in intrahepatic bile duct destruction leading to cholestasis and end stage liver disease.

Affects middle-age women of Northern European descent.

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6
Q

How is the Dx of PBC confirmed?

A

2 of the 3:

  • positive for Anti-mitochondrial Antibody
  • elevated alkaline phosphatase
  • liver biopsy shows intrahepatic bile duct destruction
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7
Q

DDx when AST and ALT elevated, but alkaline phosphatase is normal/minimally changed

A

Drugs, Alcohol, hepatitis, alpha antitrypsin deficiency, hemochromatosis

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8
Q

DDx when Alkaline phosphatase and GGT are elevated but AST and ALT are only mildly elevated

A

cholestatic pattern of liver disease

Use ultrasound to detect stones or other obstructive pathology.

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9
Q

DDx when AST and ALT are extremely high.

A 
Severe, acute hepatitis
overdose of acetaminophen
shock liver (ischemia)
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10
Q

Ratio of AST/ALT in alcohol induced hepatitis

A

> 2

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11
Q

If Alkaline phosphatase and GGT are elevated, DX?

If alkaline phosphatatase is elevated, but GGT is not, DX?

A

Cholestasis (hepatic origin)

Elevated Alk phosphate only could be due to pregnancy, bone, GI.

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12
Q

What are the most common causes of BRBPR?

A 
hemorrhoids (27-95%)
anal fissures
polyps
proctitis
rectal ulcers
cancer
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13
Q

Which ulcer is worse on an empty stomach?

A

Duodenal ulcer disease

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14
Q

What ulcer is worse with ingestion of food?

A

gastric ulcer disease

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15
Q

What is the treatment of H. pylori-associated PUD?

A

Amoxicillin + clarithromycin + PPI

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16
Q

What percentage of duodenal ulcers are associated with H. pylori?

A

90%

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17
Q

What are Mallory Weiss tears?

A

Tears in the submucosal arteries of the distal esophagus and proximal stomach due to increased intragastric pressures during vomiting. (10% of upper GI bleeding)

Tx: While bleeding stops spontaneously in 90%, sometimes vasopressin, endoscopic injection, and electrocautery are used.

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18
Q

What are esophageal varices?

A

Submucosal veins that are dilated due to portal hypertension.

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19
Q

What is the treatment for Clostridium Difficile?

A

Treat empirically

10K> x > 15K, creatinine < 1.5X baseline:
Metronidazole
15K > x > 20K, creatinine >1.5X baseline:
Oral Vancomycin (if ileum, add metronidazole or switch to rectal Vancomycin)
x > 20K WBC + Lactate > 2.2 + toxic megacolon + severe ileus:
Surgical resection

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20
Q

How is diagnosis of toxic megacolon made?

A 
Colonic distension (or thicken haustral marks) + 3 of the following:
Fever >38C
Neutrophilic leukocytosis > 10.5K
Anemia
HR > 120
\+one of the following:
Volume Depletion
Altered sensorium
electrolyte disturbance
hypotension
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21
Q

Most likely Dx for patient with subacute to chronic presentation of abdominal pain, bloody diarrhea, tenesmus.

A

Inflammatory Bowel Disease

If sepsis symptoms are present, toxic megacolon should be considered and abdominal radiograph should be done.

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22
Q

What is MEN 1?

A

Para-Pit-Pan

Parathyroid adenoma
Pituitary tumor (10-20%)
Enteropancreatic tumors (60-70%)
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23
Q

MEN 2A?

A

MPH

Medullary Thyroid Cancer
Pheochromocytoma
Hyperplasia of parathyroid

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24
Q

MEN2B or MEN 3

A

MMMP

Marfanoid Habitus
Mucosal neuromas
Medullary thyroid cancer
Pheochromocytoma

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25
Q

Symptoms and Endoscopic features of gastrinoma

A

Abdominal pain, heart burn, and diarrhea

Endoscopy shows thickened gastric folds, multiple peptic ulcers or ulcers distal to the duodenum and jejunum

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26
Q

Classic biopsy finding in Whipple’s disease?

A

PAS-positive material in the lamina propria of the small intestines.

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27
Q

Symptoms of Whipple’s disease? Cause?

A

Bacillus: Tropheryma whippelii

Abdominal pain, diarrhea, malabsorption with distention, flatulence and steatorrhea

Migratory polyarthropathy, myocardial/valvular involvement, chronic cough, hyperpigmentaton, lymphadenopathy, low grade fever

Late stage: dementia and CNS involvement: supranuclear ophthalmoplegia, myoclonus

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28
Q

Where is folic acid found?

A

Leafy greens and liver

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29
Q

Who is at risk for B12 deficiency?

A

Strict Vegetarians and Vegans

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30
Q

Symptoms of Vitamin C deficiency

A

Scurvy, perifollicular hemorrhage, swollen gums, poor wound healing

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31
Q

Vitamin D deficiency symptoms

A

Hypocalcemia tetany, osteomalacia

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32
Q

Vitamin E deficiency symptoms

A

RBC fragility, hyporeflexia, blindness, and muscle weakness

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33
Q

Increase risk factors for bleeding while on warfarin?

A

diabetes, >60 y.o., alcoholism, hypertension

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34
Q

Symptoms of retroperitoneal hematoma?

A

Signs of hemodynamic instability + back pain

Even under supratherapeutic INR

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35
Q

Diagnostic test for Zollinger-Ellison syndrome (gastrinomas)

A

Fasting serum gastrin levels >1000pg/mL
Gastric pH levels should try to exclude secondary gastrinemia.

Secretin stimulation test done: gastrinomas are stimulated by secretin, which normally inhibits

Calcium infusion study can also increase serum gastrin levels in those with gastrinomas.

36
Q

Causes of Toxic megacolon?

A 
Ulcerative colitis (within 3 years of diagnosis)
Ischemic colitis
Volvulus
diverticulitis
infection
obstructive colon cancer
37
Q

Tx of toxic megacolon

A

Bowel rest, intravenous fluids, broad spectrum antibiotics

intravenous corticosteroids are used for IBD-induced toxic megacolon

Emergency surgery: total colectomy with end-ileostomy may be required if colitis does not resolve

38
Q

What antibiotics use can lead to Clostridium difficile infection?

A

Clindamycin and fluoroquinolones

39
Q

When should patients receive PRBC?

A

Stable patients Hgb< 9g/dL

40
Q

Normal Hgb range

A

Men: 13.5-17.5 g/dL, 41-53%

Women 12-16 g/dL, 36-46%

41
Q

What is FFP? When is it indicated?

A

FFP contains all clotting factors and plasma proteins in 1 unit of blood. Indicated during active bleeding with severe coagulopathies (i.e. DIC, liver disease, supratherapeutic warfarin anticoagulation). If indicated if INR <1.6

42
Q

When are cryptoprecipitate used?

A

Those with von Willebrand factor, factor VII, fibrinogen, Factor XIII deficiency. Contains in the insoluble products of FFP.

43
Q

When are platelet transfusions given?

A

Platelets are < 10,000

Active bleeding + platelets <50,000

44
Q

What drugs can cause digoxin toxicity?

A

Amiodarone, Verapamil, Quinidine, Propafenone

45
Q

Symptoms of digoxin toxicity

A

Cardiac: Life threatening arrythmias
GI: Anorexia, abdominal pain, nausea/vomitting
Neurologic: Color visual alterations, weakness, confusion, fatigue

Acute toxicity: more GI symptoms
Chronic toxicity: more Neurologic symptoms

46
Q

Splenic Flexure

A

Watershed area between the Superior and Inferior mesenteric arteries

47
Q

Rectosigmoid junction

A

Watershed area supplied for the narrow terminal branches of the inferior mesenteric arteries

48
Q

Drugs that can cause pancreatitis?

A 
Diuretics (furosemide, thiazides)
HIV medication (didanosine, pentamidine)
Drugs for IBD (sulfasalazine, 5-ASA)
Immunosuppressive therapy (azathioprine)
Antibiotics (metronidazole, tetracycline)
49
Q

Postcholecystectomy syndrome

A

Pain or nausea that persist after a cholecystectomy due to biliary (retained common bile duct or cystic duct stone) or extrabiliary (pancreatitis, PUD, coronary artery disease)

Lab findings can show elevated liver function test, alkaline phosphatase, dilated CBD which suggests CBD stone or biliary sphincter of Oddi dysfunction.

Abdominal US should be followed by ERCP/MRCP

50
Q

What are the symptoms of VIPomas?

A

Vasoactive Intestinal Peptide

WDHA
Watery Diarrhea
Hypokalemia
Achlorhydria, Acidosis
Hypercalcemia
Vasodilation (hypotension and flushing)
hyperglycemia
51
Q

Diagnosis of VIPoma

Tx?

A

Stool has osmolarity < 50 mOsm/kg
VIP levels > 75pg/mL
CT shows mass in pancreatic tail (where 75% is located)

Octreotide + intravenous volume repletion + possible hepatic resection if metastasis to liver

52
Q

What are the symptoms of carcinoid syndrome?

A 
Skin: Flushing, cyanosis, telangectasia
Gastrointestinal: cramping, diarrhea
Cardiac: valvular lesions (right>left)
Pulmonary: bronchospasms
Miscellaneous: Niacin deficiency (pellagra, dermatitis, diarrhea, dementia)
53
Q

Diagnosis of Carcinoid Syndrome

A

Elevated 24 hr urinary excretion of 5-HIAA
CT/MRI to localize abdominal tumor
OctreoScan to detect metastasis
Echocardiogram (if symptoms of a carcinoid heart disease are present)

54
Q

Tx for Carcinoid Syndrome

A

Octreotide for symptomatic patients prior to surgery

Surgery for liver metastases

55
Q

What are carcinoid tumors?

A

Slow growing tumors in the small intestines and proximal colon. Releases histamine, serotonin, and VIP which are metabolized in the liver.

56
Q

Features of Crohn’s disease

A 
mouth-to-anus involvement
Transmural involvement of colon
Non-caseating granulomas
skip lesions
cobblestoning
Creeping fat in the mesentery 
Fistula
57
Q

Pellagra

A

Niacin deficiency resulting in dementia, dermatitis, and diarrhea.

58
Q

Normal anion gap metabolic acidosis

A 
Fistula
Ureteral diversion
Saline
Endocrine
Diarrhea
Carbonic anhydrase inhibitors
Ammonium chloride
Renal Tubular Acidosis
59
Q

Equation of anion gap

A

AG = Na - [serum Cl + serum HCO3] = 8-12 mEq/L

60
Q

What are renal tube acidosis?

A

Non-anion gap metabolic acidosis in the presence of preserved kidney function.

Type 4 RTA = hyperkalemia RTA as a result of aldosterone deficiency, resistance, diabetes where elderly has an injured juxtaglomerular apparatus. Also presents with mild-to-moderate renal insufficiency.

61
Q

Criteria for an endoscopy when a patient has GERD symptoms.

A

Men age >50 with symptoms for >5 years or cancer risk factors (i.e. tobacco use) OR alarm symptoms (melena, persistent vomiting, hematemesis, weight loss, anemia, dysphagia/odynophagia)

62
Q

Management of GERD symptoms if < 50 y.o. or not showing alarm symptoms

A

Once daily PPI for 2 months.
If refractory, switch to different PPI or 2x daily.
If refractory, consider endoscopy or esophageal pH monitoring.

63
Q

Clinical presentation of chronic pancreatitis

A 
Epigastric pain
Intermittent painless periods
Malabsorption
Diarrhea
Weight loss
Type 2 Diabetes
64
Q

Diagnosis of Chronic pancreatitis

A

CT showing pancreatic calcifications (diagnostic)

MRCP/ERCP can visualize fibrosis in the ducts

65
Q

Tx of Chronic pancreatitis

A

Frequent small meals
Pancreatic enzymes supplementation
Alcohol and smoking cessation
Pain management

66
Q

Symptoms of Celiac Disease

A

General: Bulky, foul-smelling, floating stools
Fat and Protein: loss of muscle mass, subcutaneous tissue, fatigue
Iron: Iron deficiency anemia
Vitamin K: easy bruising
Calcium, Vit D: Bone pain (osteomalacia), fractures (osteoporosis)

67
Q

Diagnosis of acute pancreatitis

A

2 of the following:

-Epigastric pain that often radiates the back
-Amylase and lipase > 3x normal
-Enlarged hyperechoic pancreas on ultrasound (gallstones)
Focal of diffuse pancreatic enlargement with heterogenous enhancement on CT

68
Q

Complications of acute pancreatitis

A

pleural effusions
ileus
Pancreatic pseudocyst
Acute respiratory distress syndrome

69
Q

Characteristics of esophageal dysmotility caused by scleroderma.

A

Decrease in LES tone. Decrease in motility of the lower 2/3 of the esophagus

70
Q

How is Crohn’s disease diagnosed?

A

Friable mucosa on colonoscopy

Mucosal inflammation on biopsy

71
Q

Extraintestinal manifestation of Ulcerative Colitis

A

Uveitis
Sclerosing Cholangitis
Erythema nodosum
spondyloarthropathy

72
Q

BUN/creatinine ratio goes up when?

A

Steroid administration
GI bleeding (due to resorption of of blood from GI tract)
prerenal renal failure

73
Q

When does IBD present

A

Bimodal: around 20 and 60’s.

74
Q

Clinical features of Zenker’s diverticulum

A 
>60 years old
Male
halitosis
dysphagia
regurgitation & aspiration
variable neck mass
75
Q

Diagnosis of Zenker

A

Esophagram

Manometry

76
Q

Management of Zenker’s

A

Open/endoscopic surgery

Cricopharyngeal myotomy

77
Q

Environmental risk factors for pancreatic cancer

Hereditary factors

A

Cigarette smoking
Low physical activity/obesity

First-degree relative with pancreatic cancer
Hereditary pancreatitis
BRCA1/BRCA2
Peutz-Jeghers

78
Q

Diagnosis of Primary Sclerosing Cholangitis

A

ERCP/MRCP detecting multifocal narrowing with intrahepatic and extra hepatic dilation. Liver biopsy would show intrahepatic ductular obliteration with moderate lymphocytic infiltration and peri-ductular “onion-skin” fibrosis.

79
Q

What is dyspepsia?

A

Epigastric fullness and pain after eating are typical symptoms

80
Q

Management of dyspepsia

A

If NSAID use, stop taking NSAIDs
If GERD, use an acid suppressant
If age >55 or alarm symptoms, Endoscopy.
If not, perform h. pylori testing. If positive, treat h. pylori. If negative, give a 4-6 trial PPI.

81
Q

HIV positive (CD4 < 180), with chronic severe diarrhea, with stool specimen with 4-6mm oocytes. Cause?

A

Cryptosporidium parvum.

82
Q

Management of hyperbilirubinemia

A

If mostly unconjugated, overproduction (hemolysis), reduced uptake (drugs, portosystemic shunt), Conjugation defect (eg. Gilbert’s syndrome)

If mostly conjugated, look at the LFTs.
If elevated AST and ALT - Viral hepatitis, autoimmune hepatitis, hematochromatosis, toxin-drug hepatitis, ischemic hepatitis, alcoholic hepatitis

Normal AST and ALT - Dubin Johnson syndrome, Rotor’s syndrome

Predominantly elevated alkaline phosphatase - cholestasis of pregnancy, malignancy, cholangiocarcinoma, PSC, PBC choledocholithiasis [need CT, and AMA testing]

83
Q

Afebrile, coughing up yellow, blood tinged sputum

A

Acute bronchitis probably viral in nature. Supportive care and observation.

84
Q

What is Well’s criteria?

A

Scoring for probability of DVT. Includes previous hx of DVT, recent immobility, pitting edema, recently bedridden for >3 days, calf swelling >3cm compared to other leg.

> =2 likely DVT

85
Q

DDx of DVT?

A

Cellulitis, venous insufficiency, Ruptured Baker’s cyst, prothrombotic syndrome

86
Q

Management of DVT

A

Well’s criteria >=2 –> Compression ultrasound
If positive => Anticoagulation therapy
If negative => If still suspicious, repeat ultrasound in 5-7 days

Well’s criteria D-dimer
If positive –> compression ultrasound
If negative –> unlikely to be DVT

Internal Medicine (4 decks)

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