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GI Flashcards

1
Q

Tx: Cholelithiasis in non-surgical candidate

A

Ursodeoxycholic Acid

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2
Q

Dx: Cholecystitis

A
  • RUQ U/S
  • If equivocal = HIDA
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3
Q

Tx: Cholecystitis in non-surgical candidate

A

Cholecystostomy

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4
Q

Dx: Choledocholithiasis

A
  • RUQ U/S
  • MRCP
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5
Q

Tx: Choledocholithiasis

A
  1. IVF, NPO, IV Abx
  2. Urgent ERCP or Cholecystectomy with intraoperative cholangiogram
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6
Q

Dx: Cholangitis

A
  • RUQ U/S
  • Clinical
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7
Q

Tx: Cholangitis

A
  1. IVF, NPO, IV Abx
  2. Emergent ERCP or Cholecystectomy with intraoperative cholangiogram
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8
Q

Abx used in cholangitis

A
  • Cipro + Metronidazole
  • Amp/Gent + Metronidazole
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9
Q

Tx: Pill-induced Esophagitis

A
  • EGD to remove pill
  • PPI
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10
Q

Tx: Infectious Esophagitis

A
  • Candida = Fluconazole
  • HSV = (val)acyclovir
  • CMV = (Val)gancyclovir
  • HIV = HAART (b/c this is AIDS-defining illness)
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11
Q

Tx: Eosinophilic Esophagitis

A
  • 1st: PPI (b/c GERD can cause eosinophilia)
  • 2nd or if already on PPI: oral aerosolized steroids (Budesonide)
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12
Q

Tx: Caustic Esophagitis

A
  • If (+) Stridor = intubate ppx
  • Low severity = NPO then liquids at 24 hr
  • High severity = NPO x 72 hours; then f/u EGD to determine if safe for escalation, presence of strictures
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13
Q

Drugs most likely to cause Pill-induced Esophagitis

A
  • NSAIDs
  • Abx: Doxycycline (tricyclics); TMP-SMX (Bactrim), Clindamycin
  • Anti-retrovirals (NRTIs)
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14
Q

Histology of Barrett’s Esophagus

A

Metaplasia from smooth mm of the distal esophagus to columnar epithelium (similar to small intestine)

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15
Q

Ppx in pt w/ PUD who cannot stop NSAIDs

A

**PPI**

If can’t take PPI, Misoprostol

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16
Q

PUD + Persistent Diarrhea

Next step?

A

Serum Gastrin Level

  • >1600 = Zollinger-Ellison
  • 250-1600 = Secretin Stim Test
    • Increased Gastrin = ZE
  • < 250 = Ruled out
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17
Q

Positive for ZE Syndrome. Next step?

A

Somatostatin Scintigraphy to localize tumor

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18
Q

Suspect H. pylori. Next step?

A
  • Never been treated before = serology
  • Treated before = Urea breath test
    • Must be off PPI
  • Best test: EGD + Bx
    • Get Histology
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19
Q

Test for eradication of H. pylori

A

Stool Ag

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20
Q

Triple Therapy

A

“CAP that H. pylori ulcer”

  • Clarithromycin
  • Ampicillin
    • Metronidazole if Penicillin-allergic
  • PPI
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21
Q

Tx: Gastroparesis

A
  • Acute
    • IV Erythromycin
  • Chronic
    • PO Metoclopramide
  • Diabetes control
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22
Q

Drugs Contra in Gastroparesis

A
  • Opiates
  • Anticholinergics
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23
Q

Dx: Gastroparesis

A
  • EGD to rule out other dz
  • Nuclear Emptying Study
    • must stop opiates and anticholinergics. Good glucose control.
    • >60% at 2 hours = (+)
    • >10% at 4 hours = (+)
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24
Q

Enlarged lymph node in left supraclavicular fossa indicates?

A

Gastric Cancer

(called Virchow’s Node)

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25
Q

Tx: Gastric cancer, Bx shows lymphoma

A

MALToma

Tx: Triple Therapy

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26
Q

Tx: Gastric cancer, Bx shows signet ring cells

A

Gastric Adenocarcinoma

Tx: Stage w/ PET-CT; Resection and Chemo

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27
Q

Risk factors for Gastric Adenocarcinoma

A

Diet rich in Nitrites (smoked fish)

Usually E. Asian

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28
Q

Etiology & Tx of Cyclic Vomiting Syndrome

A
  • Ethiology
    • THC
  • Tx:
    • Stop THC
    • Metoclopramide
    • Erythromycin
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29
Q

Side effects limiting Metoclopramide use in Gastroparesis

A

Tardive Dyskinesia

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30
Q

Most sensitive test for invasive bacteria

A

Lactoferrin

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31
Q

Best test for C. diff

A

C. diff NAAT

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32
Q

Tx: repeated recurrences of C. diff

A

Fidaxomicin

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33
Q

Bloody diarrhea + Low Hgb + Elevated Cr. Next step?

A

HUS

  • Dx:
    • serum shiga toxin
    • E. coli O157:H7 culture
  • Tx: Plasma exchange, supportive
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34
Q

Work-up for chronic diarrhea

A
  • Stool Osmolar Gap
    • Measured Osm (290) - Calculated Osm ((Na + K)*2)
    • < 50 = Secretory
    • >100 = Osmotic
  • Fecal WBC
  • FOBT
  • Fecal Fat
  • NPO
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35
Q

Pt w/ diarrhea has an osmotic gap of 110, increased fecal fat, and decreased diarrhea w/NPO. Dx?

A

Osmotic Diarrhea

(likely malabsorption)

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36
Q

Pt w/ diarrhea has a normal osmotic gap, normal fecal fat, no fecal blood cells, and no change with NPO. Dx?

A

Secretory Diarrhea

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37
Q

Dx and next step: Secretory Diarrhea + refractory ulcers

A

Gastrinoma

  • Serum gastrin
    • <350 = r/o
    • >1600 = r/i
    • in between = secretory stimulation test
  • If r/i
    • Somatostatin Receptor Scintillography (SRS)
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38
Q

Dx and Next Step: Secretory Diarrhea + flushing + heart problems

A

Carcinoid metastasized to liver

  • Dx
    • Urinarry 5-HIAA to confirm
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39
Q

Dx and Next Step: Secretory Diarrhea + Pancreatic Mass

A

VIPoma

  • Dx:
    • High serum VIP
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40
Q

Pt w/ diarrhea has blood cells and mucus in stool

A

Inflammatory Diarrhea

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41
Q

Dx: Positive anti-endomysial and tissue transglutaminase abs

A

Celiac Disease

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42
Q

Dx & Tx: Picture of celiac dz but in a Carribean farmer

A

Tropical Sprue

  • Dx:
    • Abs = negative
    • EGD + Bx = villous blunting
  • Tx:
    • Abx: TMP-SMX (Bactrim)
43
Q

Pt has the rash shown on extensor surfaces and the buttocks. Next step?

A
  • Dx
    • Antibodies:
      • best: anti-tissue transglutaminase
      • anti-endomysial
    • If Ab negative but strong suspicion = EGD + Bx
44
Q

Pt has elevated fecal fat, suspicious of malabsorption diarrhea. What is the next diagnostic step?

A

D-Xylose + CT scan

  • Absorbed = Pancreatic Deficiency
    • Tx: Supplement pancreatic enzymes
  • Not absorbed = Intestinal Border Deficiency
    • Dx: EGD + Bx
45
Q

Dx: Pt has malabsorption diarrhea with brain/lymph/joint problems.

A

Whipple Disease

  • Dx:
    • EGD Bx
      • Light microscopy = PAS+ Microphages
      • Electron microscopy = see organisms
    • PCR of blood/CSF
46
Q

Tx: Pt w/ Osmotic diarrhea, PAS+ Macrophages on light microscopy

A

Long-term Abx

  • TMP-SMX (Bactrim)
  • Doxycycline
47
Q

Pt is a middle-aged woman with normal periods, iron-deficiency anemia, and osteoporosis. Next step?

A

Look for Celiac Sprue

(Malabsorption at proximal duodenum of FIC - Folate, Iron, Calcium)

  • Dx:
    • Abs (anti-tTG or anti-endomysial)
    • If negative, EGD + Bx
48
Q

Tx: Mild Ulcerative Colitis

A

5-ASA compounds

  • Mesalamine
  • Sulfasalazine
49
Q

Tx: Moderate Ulcerative Colitis

A

Immune Modulators

  • 6-MP
  • Azathioprine
  • MTX (last resort)
50
Q

Tx: Ulcerative Colitis Flare

A
  1. Rule out C. diff (NAAT)
  2. Steroid (Prednisone) + Abx (Cipro + MTZ)
51
Q

Tx: Severe Ulcerative Colitis

52
Q

Tx: Mild Crohn’s Dz

A

Can try 5-ASA compounds

  • Mesalamine
  • Sulfasalazine
53
Q

Tx: Moderate Crohn’s Dz

A

Immune Modulators

  • 6-MP
  • Azathioprine
  • MTX (last resort)
54
Q

Tx: Crohn’s Dz Flare

A
  1. Rule out C. diff
  2. Steroids (Prednisone) + Abx (Cipro + MTZ)
55
Q

Tx: Severe Crohn’s Dz

A

TNF-alpha inhibitors

  • Infliximab
56
Q

Tx: Diverticulitis

A
  1. Bowel rest
  2. Abx
    • Cipro + MTZ
    • Amp/Gent + MTZ
57
Q

Pt w/ “left-sided appendicitis.” Next step?

A
  1. PA (upright) CXR to rule out perforation of possible diverticulitis
  2. CT scan - diagnose and determine extent of disease
58
Q

When should colonoscopy be performed in diverticulitis?

A

2-6 wks post-diverticulitis to screen for cancer

59
Q

Dx: Diverticular hemorrhage

A
  1. Tx like GI bleed
    • 2 large bore IVs
    • IVF
    • Type and cross
    • IV PPI
  2. Rule out upper GI bleed
    • NG tube + EGD
  3. Find bleed
    • Fast bleed = angiogram (with embolization)
    • Slow bleed = tagged RBC
    • Stopped bleeding = colonoscopy
60
Q

Tx: Colon cancer

A
  • No spread (stage I/II) = resection
  • Stage III/IV
    • FOLFOX
      • 5-Fu
      • Leucovorin
      • Oxaliplatin
    • FOLFIRI
    • Add Bevacizumab (VEGF-i)***
61
Q

Mutation in FAP

A

APC gene mutation

62
Q

Mutation in HNPCC

A

DNA mismatch repair

63
Q

Types of cancers in HNPCC

A

HNPCC = Lynch Sydrome

Think Meryl Lynch, CEO

  • Colon
  • Endometrial
  • Ovarian
64
Q

Colon cancer + brain tumor

A

Turcot Syndrome

65
Q

Colon Cancer + Osteochondroma of the jaw

A

Gardner’s Syndrome

66
Q

Colon polyps + macules in/around mouth

A

Peutz-Jeghers

Look for small intestinal hamartomas

No colon cancer

67
Q

Dx: Pancreatitis

A
  • Lipase > 3x ULN (best)
  • Amylase > 3x ULN
  • If stones suspected: RUQ U/S -> ERCP
  • Symptoms present, but enzymes not elevated
    • CT scan
68
Q

Tx: Gallstone Pancreatitis

69
Q

Etiology Pancreatitis

A

Most common: Gallstones, EtOH

PANCREATITS

  • Parathyroid hormone
  • Alcohol
  • Neoplasia
  • Calcium
  • Rocks (gallstones)
  • Estrogens
  • ACE-i
  • Triglycerides
  • Infarction (ischemia)
  • Trauma (ERCP, MVA)
  • Infection (mumps)
  • Scorpion stings
70
Q

Acute pancreatitis diagnosed in last couple days + hypoTN. Dx and management?

A

Necrotizing Pancreatitis

  • Dx:
    • CT scan = necrosis
    • Biopsy (required before giving Abx)
  • Tx:
    • Meropenem
71
Q

Hx of Acute pancreatitis + Early satiety + Abdominal fullness. Dx and managment?

A

Pancreatic Pseudocyst

  • Dx:
    • CT Scan
  • Tx: 6&6 Rule
    • < 6 cm & < 6 weeks = observe
    • > 6 cm or > 6 weeks = drain + bx (r/o cancer)
72
Q

Treatment of Pleural Effusion or Ascites associated with Pancreatitis

A

Do not tap/put in chest tube UNLESS Infected

73
Q

Suspect Wilson’s Disease. Next best step?

A

Slit lamp looking for Kaiser-Fleischer Rings

  • Other Options
    • Ceruloplasmin = low
    • Urine Copper = high
    • Best = Bx = high Cu
74
Q

Bronze Diabetes suspected. Next best step?

A

Ferritin level = very elevated (>1,000)

  • Other options:
    • Transferrin > 50% (better)
    • Bx = elevated iron (best)
75
Q

Alpha 1 Anti-Tripsin Def suspected. Next best step?

A

Bx = PAS + Macrophages

Best: Phenotyping (PiZZ worst; PiMM normal)

76
Q

PSC suspected. Next best step?

A

MRCP = beads on a string

If bx obtained = onion skinning fibrosis

77
Q

Tx PSC

A

Symptomatic Relief: Cholestyramine, Ursodeoxycholic Acid (?)

Transplant (can recur)

78
Q

PBC Suspected. Next best step?

A

Serology = AMA +

Bx

79
Q

Tx PBC

A
  • First: Ursodeoxycholic acid
    • Think Ursela from the little mermaid
  • Transplant (curative)
80
Q

Woman with cirrhosis. AST and ALT in the 1000s. Dx and best next step?

A

Autoimmune Hepatitis

  • Dx:
    • Serology
      • Anti Smooth Muscle Ab
      • Anti LKM Ab
    • Best = Biopsy
81
Q

Tx Autoimmune Hepatitis

A

Steroids, then transplant

82
Q

AST and ALT in the 1,000s in setting of cirrhosis. Dx?

A
  1. Autoimmune Hepatitis
  2. Acetaminophen toxicity
  3. Aflatoxin
  4. Acute Viral Hepatitis (A,B)
  5. Shock Liver (hypoTN)
  6. Budd Chiari
83
Q

Dx: Cirrhosis

A
  1. RUQ U/S (to ID cirrhosis)
  2. CT/MRI (evaluate for nodules or masses)
  3. Biopsy, transjugular (best test)
84
Q

Screening for HCC in Cirrhotic Pts

A

AFP and RUQ U/S q6mo

85
Q

Vaccinations Needed in Cirrhotic Pts as Ppx

A

Hep A and Hep B

86
Q

Dx: SBP

A

Paracentesis with gram stain and culture

Dx: >250 PMNs + 1 organism seen

87
Q

Tx: SBP

A

Ceftriaxone (3rd gen cephalosporins)

or

Cipro (Fluoroquinolones)

88
Q

Ppx against SBP

A

Give FQ qWeek if:

  1. Hx of SBP
  2. TP < 1.0
89
Q

Dx: Secondary Bacterial Peritonitis

A
  • Paracentesis with gram stain and culture
    • >250 PMNs
    • At least 2 organisms seen
90
Q

Tx: Secondary Bacterial Peritonitis

A
  • Tx:
    • MTZ + CTX
    • Ex-Lap to find perforated bowel
91
Q

Pt with cirrhosis has platypnea. Dx?

A

Hepatopulmonary syndrome

  • Dx: 2D ECHO with Bubble Study
    • (+) if reveals bubbles every 3-6 beats

Platypnea (opposite of orthopnea)

Path: Vasodilation of pulm artery creates functional R->L shunt

Tx: Transplant

92
Q

Cirrhosis + Renal Failure in absence of definitive cause. Dx and Tx?

A

Hepatorenal Syndrome

  • Dx:
    • rule out other causes of renal failure
  • Tx:
    • Hold diuretics
    • Give Albumin
    • Give Octreotide
93
Q

Dx and Tx: Hepatic Encephalopathy

A
  • Dx
    • Clinical
    • (don’t get ammonia levels!!)
  • Tx:
    • Lactulose
    • Rifaximin + Zinc
94
Q

Confirmatory test for HCC?

A

Triple-Phase CT

95
Q

Tx: HCC

A

Resection

Transplant

Radiofrequency Ablation or Chemo Embolization

96
Q

Tx: Esophageal Varices that are currently bleeding

A
  • EGD + Banding
  • Octreotide + CTX
97
Q

Asx Jaundice with stress but no dark urine

A

Unconjugated hyperbilirubinemia

Likely Gilbert’s as Crigler-Najjar is fatal early in life

98
Q

Asx jaundice with stress + dark urine

A

C Dr. Rogers

Conjugated Hyperbilirubinemia

Dubin-Johnson (Dubin = Dark Black Liver on inspection)

Rotors Syndrome

99
Q

Dx and Tx: Biliary Stricture

A
  • Dx:
    • U/S may show dilation
    • MRCP - diagnose
    • ERCP + bx - confirm stricture, no cancer
  • Tx:
    • Stent
100
Q

Postexposure Ppx for Hep A

A

IgG + Vaccine w/i 2 weeks of exposure

101
Q

Tx: Hepatitis B

A

peg IFN-alpha-2a + antivirals (-fovir, -cavir, -vudine)

Antivirals: adefovir, entecavir, lamivudine, telbivudine

102
Q

Screening for HCC in Hep B

A

Screen with U/S and AFP even without cirrhosis

103
Q

Tx: Hepatitis C

A
  • Genotypes 1 & 4
    • Interferon + Ribavirin
      • S/E include psychosis, depression, flu-like symptoms
  • Genotypes 2 & 3
    • Direct Acting Antagonists (protease-inhibitors) = -vir
      • Ex: borceprovir
104
Q

Screening for HCC in Hep C

A

No need unless patient is cirrhotic

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