GI Flashcards
What is the best test for PSC?
TX?
ERCP
Liver Transplant.
Stenting can be used to reduce jaundice and cholangitis.
What are the risk factors of PSC
Ulcerative Colitis
Male
What is seen on ERCP for PSC
“beads on a string”
What is the treatment for PBC?
Ursodeoxycholic Acid
Second line: Corticosteroids, Colchine, methotrexate
Curative: Liver transplantation
What is PBC?
Autoimmune disease resulting in intrahepatic bile duct destruction leading to cholestasis and end stage liver disease.
Affects middle-age women of Northern European descent.
How is the Dx of PBC confirmed?
2 of the 3:
- positive for Anti-mitochondrial Antibody
- elevated alkaline phosphatase
- liver biopsy shows intrahepatic bile duct destruction
DDx when AST and ALT elevated, but alkaline phosphatase is normal/minimally changed
Drugs, Alcohol, hepatitis, alpha antitrypsin deficiency, hemochromatosis
DDx when Alkaline phosphatase and GGT are elevated but AST and ALT are only mildly elevated
cholestatic pattern of liver disease
Use ultrasound to detect stones or other obstructive pathology.
DDx when AST and ALT are extremely high.
Severe, acute hepatitis overdose of acetaminophen shock liver (ischemia)
Ratio of AST/ALT in alcohol induced hepatitis
> 2
If Alkaline phosphatase and GGT are elevated, DX?
If alkaline phosphatatase is elevated, but GGT is not, DX?
Cholestasis (hepatic origin)
Elevated Alk phosphate only could be due to pregnancy, bone, GI.
What are the most common causes of BRBPR?
hemorrhoids (27-95%) anal fissures polyps proctitis rectal ulcers cancer
Which ulcer is worse on an empty stomach?
Duodenal ulcer disease
What ulcer is worse with ingestion of food?
gastric ulcer disease
What is the treatment of H. pylori-associated PUD?
Amoxicillin + clarithromycin + PPI
What percentage of duodenal ulcers are associated with H. pylori?
90%
What are Mallory Weiss tears?
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.
What are esophageal varices?
Submucosal veins that are dilated due to portal hypertension.
What is the treatment for Clostridium Difficile?
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
How is diagnosis of toxic megacolon made?
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
Most likely Dx for patient with subacute to chronic presentation of abdominal pain, bloody diarrhea, tenesmus.
Inflammatory Bowel Disease
If sepsis symptoms are present, toxic megacolon should be considered and abdominal radiograph should be done.
What is MEN 1?
Para-Pit-Pan
Parathyroid adenoma Pituitary tumor (10-20%) Enteropancreatic tumors (60-70%)
MEN 2A?
MPH
Medullary Thyroid Cancer
Pheochromocytoma
Hyperplasia of parathyroid
MEN2B or MEN 3
MMMP
Marfanoid Habitus
Mucosal neuromas
Medullary thyroid cancer
Pheochromocytoma
Symptoms and Endoscopic features of gastrinoma
Abdominal pain, heart burn, and diarrhea
Endoscopy shows thickened gastric folds, multiple peptic ulcers or ulcers distal to the duodenum and jejunum
Classic biopsy finding in Whipple’s disease?
PAS-positive material in the lamina propria of the small intestines.
Symptoms of Whipple’s disease? Cause?
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
Where is folic acid found?
Leafy greens and liver
Who is at risk for B12 deficiency?
Strict Vegetarians and Vegans
Symptoms of Vitamin C deficiency
Scurvy, perifollicular hemorrhage, swollen gums, poor wound healing
Vitamin D deficiency symptoms
Hypocalcemia tetany, osteomalacia
Vitamin E deficiency symptoms
RBC fragility, hyporeflexia, blindness, and muscle weakness
Increase risk factors for bleeding while on warfarin?
diabetes, >60 y.o., alcoholism, hypertension
Symptoms of retroperitoneal hematoma?
Signs of hemodynamic instability + back pain
Even under supratherapeutic INR
Diagnostic test for Zollinger-Ellison syndrome (gastrinomas)
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.
Causes of Toxic megacolon?
Ulcerative colitis (within 3 years of diagnosis) Ischemic colitis Volvulus diverticulitis infection obstructive colon cancer
Tx of toxic megacolon
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
What antibiotics use can lead to Clostridium difficile infection?
Clindamycin and fluoroquinolones
When should patients receive PRBC?
Stable patients Hgb< 9g/dL
Normal Hgb range
Men: 13.5-17.5 g/dL, 41-53%
Women 12-16 g/dL, 36-46%
What is FFP? When is it indicated?
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
When are cryptoprecipitate used?
Those with von Willebrand factor, factor VII, fibrinogen, Factor XIII deficiency. Contains in the insoluble products of FFP.
When are platelet transfusions given?
Platelets are < 10,000
Active bleeding + platelets <50,000
What drugs can cause digoxin toxicity?
Amiodarone, Verapamil, Quinidine, Propafenone
Symptoms of digoxin toxicity
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
Splenic Flexure
Watershed area between the Superior and Inferior mesenteric arteries
Rectosigmoid junction
Watershed area supplied for the narrow terminal branches of the inferior mesenteric arteries
Drugs that can cause pancreatitis?
Diuretics (furosemide, thiazides) HIV medication (didanosine, pentamidine) Drugs for IBD (sulfasalazine, 5-ASA) Immunosuppressive therapy (azathioprine) Antibiotics (metronidazole, tetracycline)
Postcholecystectomy syndrome
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
What are the symptoms of VIPomas?
Vasoactive Intestinal Peptide
WDHA Watery Diarrhea Hypokalemia Achlorhydria, Acidosis Hypercalcemia Vasodilation (hypotension and flushing) hyperglycemia
Diagnosis of VIPoma
Tx?
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
What are the symptoms of carcinoid syndrome?
Skin: Flushing, cyanosis, telangectasia Gastrointestinal: cramping, diarrhea Cardiac: valvular lesions (right>left) Pulmonary: bronchospasms Miscellaneous: Niacin deficiency (pellagra, dermatitis, diarrhea, dementia)
Diagnosis of Carcinoid Syndrome
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)
Tx for Carcinoid Syndrome
Octreotide for symptomatic patients prior to surgery
Surgery for liver metastases
What are carcinoid tumors?
Slow growing tumors in the small intestines and proximal colon. Releases histamine, serotonin, and VIP which are metabolized in the liver.
Features of Crohn’s disease
mouth-to-anus involvement Transmural involvement of colon Non-caseating granulomas skip lesions cobblestoning Creeping fat in the mesentery Fistula
Pellagra
Niacin deficiency resulting in dementia, dermatitis, and diarrhea.
Normal anion gap metabolic acidosis
Fistula Ureteral diversion Saline Endocrine Diarrhea Carbonic anhydrase inhibitors Ammonium chloride Renal Tubular Acidosis
Equation of anion gap
AG = Na - [serum Cl + serum HCO3] = 8-12 mEq/L
What are renal tube acidosis?
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.
Criteria for an endoscopy when a patient has GERD symptoms.
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)
Management of GERD symptoms if < 50 y.o. or not showing alarm symptoms
Once daily PPI for 2 months.
If refractory, switch to different PPI or 2x daily.
If refractory, consider endoscopy or esophageal pH monitoring.
Clinical presentation of chronic pancreatitis
Epigastric pain Intermittent painless periods Malabsorption Diarrhea Weight loss Type 2 Diabetes
Diagnosis of Chronic pancreatitis
CT showing pancreatic calcifications (diagnostic)
MRCP/ERCP can visualize fibrosis in the ducts
Tx of Chronic pancreatitis
Frequent small meals
Pancreatic enzymes supplementation
Alcohol and smoking cessation
Pain management
Symptoms of Celiac Disease
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)
Diagnosis of acute pancreatitis
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
Complications of acute pancreatitis
pleural effusions
ileus
Pancreatic pseudocyst
Acute respiratory distress syndrome
Characteristics of esophageal dysmotility caused by scleroderma.
Decrease in LES tone. Decrease in motility of the lower 2/3 of the esophagus
How is Crohn’s disease diagnosed?
Friable mucosa on colonoscopy
Mucosal inflammation on biopsy
Extraintestinal manifestation of Ulcerative Colitis
Uveitis
Sclerosing Cholangitis
Erythema nodosum
spondyloarthropathy
BUN/creatinine ratio goes up when?
Steroid administration
GI bleeding (due to resorption of of blood from GI tract)
prerenal renal failure
When does IBD present
Bimodal: around 20 and 60’s.
Clinical features of Zenker’s diverticulum
>60 years old Male halitosis dysphagia regurgitation & aspiration variable neck mass
Diagnosis of Zenker
Esophagram
Manometry
Management of Zenker’s
Open/endoscopic surgery
Cricopharyngeal myotomy
Environmental risk factors for pancreatic cancer
Hereditary factors
Cigarette smoking
Low physical activity/obesity
First-degree relative with pancreatic cancer
Hereditary pancreatitis
BRCA1/BRCA2
Peutz-Jeghers
Diagnosis of Primary Sclerosing Cholangitis
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.
What is dyspepsia?
Epigastric fullness and pain after eating are typical symptoms
Management of dyspepsia
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.
HIV positive (CD4 < 180), with chronic severe diarrhea, with stool specimen with 4-6mm oocytes. Cause?
Cryptosporidium parvum.
Management of hyperbilirubinemia
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]
Afebrile, coughing up yellow, blood tinged sputum
Acute bronchitis probably viral in nature. Supportive care and observation.
What is Well’s criteria?
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
DDx of DVT?
Cellulitis, venous insufficiency, Ruptured Baker’s cyst, prothrombotic syndrome
Management of DVT
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
