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ABIM > GI 3 > Flashcards

GI 3 Flashcards

1
Q
  1. Occurs in Old Institutionalized Men (Nursing Home) they presents with abdominal pain, constipation or diarrhea, active bowel sounds and DISTENDED ABDOMEN WITHOUT ANATOMIC Obstruction. Dx?
  2. Test?
  3. Management?
  4. What if no improvement with initial management?
    Whom is it contraindicated ?
  5. Next step in Management for those that fail that treatment?
A

Ogilvie Syndrome. (Risk Factors: medications, dementia, electrolyte disturbance, recent surgery/injury/ trauma.)

  1. CT scan shows Dilated Abdomen.

Conduct Serial Abdominal examinations to asses for Perforation

  1. NG tube Decompression (Supportive Rx).
  2. Give Neostigmine if no improvement after 48 hrs.
    (It is toxic & Contraindicated in Cardiac disease or Active bronchospasm - causes hypotension and bradycardia)
  3. Colonoscopic or Surgical Decompression for those who fail neostigimine
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2
Q

Pt with Celiac Disease and Poor Adherence to diet. He presents with 3 months of Abdominal Pain, Melena and Diarrhea, Night Sweats and Weightloss ?

A

Enteropathy-Associated T cell lymphoma. (Small Bowel Lymphoma)

Strict Gluten Free diet reduces risk.

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3
Q

What is common in an elderly institutionalized patient with Diffuse Tender Distended Abdomen with Air Filled Sigmoid Colon?

Rx?

What does air under the diaphragm indicate?

A

Sigmoid Volvulus

Sigmoidoscopy

Perforation

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4
Q
  1. Vomiting, Preformed toxin in rice?
  2. Vomiting, Symptoms occur within 1-6 hrs, preformed toxin? (Picnic)
  3. Vomiting, diarrhea due to Raw or Undercooked Shellfish ?
  4. Watery diarrhea due to Abx exposure?
  5. Watery diarrhea due to Undercooked or Unrefrigerated food
  6. Watery diarrhea due to undercooked Poultry & Eggs?
  7. Watery diarrhea (bloody if there is shiga-toxin producing due to undercook Beef and Foods contaminated with bovine feces?
  8. Bloody diarrhea associated with contaminated food and water especially during travel outside US?
  9. Bloody diarrhea associated with Raw and Undercooked Meats/Poultry, seen in Children and Young adults
A
  1. Bacillus Cerus
  2. Staph
  3. Vibrio
  4. C. Diff
  5. C. Perfrinigens
  6. Salmonella
  7. E. Coli, travelers diarrhea
  8. Shigella
  9. Camplylobacter
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5
Q
  1. Management of Infected Necrotizing Pancreatitis ?
  2. Next step in management if they fail that treatment?
A
  1. Treat empirically with abx (Carbepenem or Levaquin+ Metronidazole ) OR Perform CT-guided FNA to Help direct abx treatment
  2. Necrsecotmy (Surgical Debridement)
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6
Q
  1. What is the initial management of a UC flare?
  2. When do you give antibiotics?
  3. What happens if they are refractory to initial treatment.
A
  1. Systemic Steroids + High dose 5 aminosalicyclic Acid (Mesalamine)
  2. Give Abx in Severe UC when patient has Signs of Systemic Toxicity (Fever, Marked Leukocytosis, Left shift)
  3. If improvement transition to Oral steroids.
    When patients are refractory they require Cylosporine or TNF inhibitor, if no improvement after that then Colectomy.
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7
Q

Chronic diarrhea and flushing. What is the metabolite associated with this disorder?

A

Carcinoid Tumor

Serum 5-hydroxyindoleacetic acid (serotonin metabolite)

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8
Q

Chronic Abdominal Pain, Flushing, Hypotension, HA, Syncope, fatigue, Pruritus.

Dx?
Rx?

A

Mastocytosis

Serum Tryptase

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9
Q

First initial test for Suspect Ischemic Colitis?

A

CT scan to r/o extensive bowel injury

Then Colonoscopy (Can see Areas of Petechiae and Bluish Areas)

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10
Q
  1. First step in management for Acute Upper GI Bleed?
  2. What must be completed in first 24 hrs?
  3. What are the HIGH RISK features (3) that warrant recurrent bleeding with Admission to Medical Ward on Clear Liquid Diet?
A
  1. NPO, IVF, IV PPI
  2. Endoscopy must be completed within 24 hrs
  3. Active Bleeding, Adherent Clot, Visible Vessel

Needs hospitalization for atleast 3 days.

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11
Q

Screening for Colonoscopy.

What 2 groups are at an increased risk ?

A
  1. First-Degree Relative age < 60 with Colon Cancer or Adenomatous Polyps
  2. (2) First Degrees at ANY Age with Adenomatous Polyp or Cancer.
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12
Q

Management of a patient who Presents with DISTAL Hyperplastic Polyps on Colonoscopy.

What happens if they are Proximal?

Management of young patient with 30 small (< 10mm) Sessile Polyps seen in Fundus on Endoscopy?

Post polypectomy surveillance:

  1. 1-2 tubular adenomas
  2. 3-10 adenomas , > 10mm, villous histology, high grade dysplasia
  3. > 10 adenomas
A

Colonoscopy every 10 years. Average Risk

If pt presents with > 5 and they are PROXIMAL then concerns for Hyperplastic Polyposis Syndrome (High Risk Cancer.)

Colonoscopy to check for Polyposis in colon genetic testing for FAP.

  1. 5-10 yrs
  2. 3 yrs
  3. < 3 years
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13
Q
  1. Rx for Fulminant C diff?
  2. Rx for C. Diff recurrence?
A
  1. High dose Oral vancomycin and IV Metronidazole
  2. Fidoxamicin or Pulse Tapered Vancomycin
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14
Q

Difference between Acute onset Mesenteric Ischemia and Chronic Mesenteric Ischemia?

A

In Acute Mesenteric Ischemia Pain is Acute and Severe.

Associated with elevated lactate and Acidosis, Leukocytosis.

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15
Q

Rx of severe UC?

Rx of Steroid Refractory Severe UC?

A
  1. Systemic Steroids and High dose 5-ASA
  2. Cyclosporine and TNF-inhibitor (Inflixmab)
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16
Q

82 yo person with significant lower GI bleeding, Endoscopy and Colonoscopy reveals NO source of bleeding (No hemorrhoids, Diverticulosis, Malignancy or IBD) .

  1. Dx?
  2. What is this associated with?
A
  1. Andgiodysplasia or (AVM)
  2. Aortic Stenosis
    Seen in elder patients > 60.
17
Q

Pt presents with Abdominal Bloating, Flatulence, Bulky loose stools and Watery diarrhea 3-4x a week.
Pt is s/p Roux-En-Y.

Dx?
Test?

A

SIBO

Positive Hydrogen Breath Test
OR
Jejunal aspiration and Culture
(Showing high levels of Bacterial Colonization)

18
Q

Diabetic patient presents with watery diarrhea that wakes them up at night, fecal incontinence. Colonoscopy is Normal!

Dx?

Test?

A

SIBO
Ccommon in Diabetics due to Hypomolilty due to Autonomic Neuropathy - Diabetic Diarrhea

Hydrogen Breath Test
Jejunal Aspiration

19
Q

Pt presents with chronic Watery Diarrhea without bleeding.
Colonoscopy show grossly normal mucosa with lymphocytic infiltrates on biopsy.
Dx?
Initial treatment?
2nd line therapy?

A

Microscopic Colitis

Anti-diarrheals and stop offending agents (NSAIDs)

Oral Budesnoside

20
Q

Pt presents with Nausea, Vomiting, Lipase Elevation, Inability to Pass Gas, NO stool in rectal vault and NO Abdominal Distention

  1. Dx?
  2. What is the next step step in management?
  3. Treatment for SBO?
A
  1. Small Bowel Proximal Obstruction (Abdomen is distended with more distal disease) (Shows air-fluid levels and distended small bowel loops.)

—- Actual Anatomic Obstruction———

  1. Plain upright CXR.
    Can do an CT Abdomen with Oral and IV contrast if AXR is not diagnostic
  2. Non OPERATIVE: NPO, Fluid Resuscitation, Electrolyte Repletion and Serial abdominal examinations (Like Oligovie Syndrome)
21
Q
  1. When patient presents with Positive Stool Occult Test and Iron Deficiency anemia what is the next step in management?
  2. What if those test are negative?
A
  1. Combination Upper Endoscopy and Colonoscopy
  2. Conduct Wireless Capsule Endoscopy
22
Q

Hiker presents with Diarrhea, Steatorrhea, abdominal cramps and bloating.

Next step in management?

A

Stool Microscopy or Stool immunoassay for Giardia Cyst

23
Q

Management of Factious diarrhea:

  1. Osmolality < 250?
  2. Osmolality > 400?
  3. When it is 250-400?
A

Osmotic gap < 50 = secretory diarrhea

Osmotic gap > 125 = osmotic diarrhea

  1. Rule out water being added
  2. Rule out urine being added
  3. Check osmotic gap : if < 75 saline laxative (senna, Bisacodyl.)
    If > 75 then measure fecal fat and r/o lactulose, sorbitol, mag sulfate, poly glycol
24
Q

Pt presents with Rectal Tenesmus, Purulent Discharge, Small- Volume containing Stools.

Dx?

Organism?

A

Proctitis

N. Gonorrhoeae

25
Q

What is the preferred treatment for anal fissures?

A

Topical Nitroglycerin Cream
(It improves blood floor to promote wound healing)

26
Q

Give Prophylaxis Recommendations for each:

  1. Cirrhosis WITHOUT Varices or Small NonBleeding Varices
  2. Medium Large Varices
  3. Small Varices with Red Wale sign or Decompensated cirrhosis
A
  1. No beta blockers
    Every 2-3 years in Compensated Disease
    Yearly in Decompensated
  2. Endoscopic Variceal Ligation or Beta blocker (Propanolol, Nadolol), Yearly EGD
  3. Beta blocker & Yearly EGD
27
Q

Asymptomatic Isolated Unconjugated Hyperbilirubinemia with Normal LFTS Dx? Rx?

A

Gilbert Syndrome

No further testing or treatment needed

28
Q

Name 3 Extra-hepatic Causes of elevated LFTs?

A
  1. Celiac Disease
  2. Hypothyroidism
  3. Muscle Disorders
29
Q
  1. Initial Management when a patient presents with Ascites?
  2. What is the next step if SAAG > 1.1. ?
  3. What if Sodium is < 120
  4. What if NO improvement and Serum Sodium > 120?
  5. Management in Refractory Cases?
A
  1. Rule out infection (PMN> 250) and calculate SAAG.

(Serum Albumin- Ascitic Albumin )

  1. Due to Portal Hypertension
    Sodium Restrict
    Avoid NSAIDs, ACE
    Alcohol Cessation
    (Can cause AKI/Pre-renal Azotemia.)
  2. Hypertonic Saline, Vasopressin
  3. High dose Spironolactone and Oral Lasix
  4. Large Volume Paracentesis, TIPS or Liver Transplant.
30
Q

Pt with hx of Chronic Peritoneal Dialysis presents with diffuse abdominal pain x 1 day, fever, abdominal tenderness, peritoneal fluid shows 110 WBCs.

Next step in management?

A

Intraperitoneal Vancomycin and Cefepime

31
Q

Pt hospitalized for CAP develops Jaundice and Scleral icterus on day 4.
D Bili and Alk phos are elevated.

Dx?

A

Think Drug-induced Cholestasis

Stop the offending agent

32
Q

22 yo M with Hx of Crohns disease presents with Diarrhea. 3 months ago he had Small bowel Obstruction that lead to Ileal resection.
Since surgery he has had 4-5 loose bowel movements a day that disrupts his daily life.
Dx? Rx?

A

Ileal resection leads to B12 and Bile Salt Malabsorption (Causes Secretory Diarrhea.)

Cholestyramine

33
Q

66 yo M presents with abdominal pain and nausea. Yesterday he had a colonoscopy and 2 polyps were removed. His abdomen is tender in the periumbilical left lower quadrant areas. AXR shows no free air under the diaphragm.

Dx?
Next Step in Management?

A

Perforation

CT Scan of Abdomen with Water Soluble Contrast.

AXR can miss subtle changes.

34
Q

What is a Refractory Celiac Sprue?
Why is this concerning?

A

Pt with persistent intestinal pathological changes despite strict Glute Free Diet. Pt do not present with B symptoms or Bloody Diarrhea.

Refractory sprue can progression to EATL

35
Q
  1. What is the initial screening test for Celiac Dz?
  2. What is commonly order since it is also often associated with Celiac Dz?
  3. What is the next step for patients with Positive serologies or Highly Suggestive Symptoms ?
  4. What other test can be diagnostic?
  5. What other things are associated with Celiac Dz?
A
  1. Order Anti-transglutaminase IgA or Anti-endomysial IgA antibodies
  2. Total serum IgA levels (IgA deficiency is commonly associated)
  3. Small Bowel Enterosocpy with Biopsy ( Gluten free diet only after test is completed to prevent False Negatives)
  4. Cutaneous Biosy to check for Dermatitis Hepetiformis.
  5. Iron deficiency, Hypothyroidism, Osteoporosis
36
Q
  1. Treatment for Mild Gallstone Pancreatitis?
  2. Treatment for Severe Gallstone Pancreatitis?
  3. Initial Treatment for Acute Cholangitis ?
A
  1. IVF, Pain Medications (Stone will pass on its on)
  2. IVF, Pain Medications —>ERCP (To help Remove Stone) and —->then Cholecystectomy when inflammation has calmed down
  3. IVF, Pain and Abx. Then ERCP, Then Cholecystectomy

ABIM (45 decks)

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