GI Flashcards
1
Q
Older pt with LLQ pain, constipation, and mildly febrile. No blood on exam. Dx?
A
Diverticulitis
Usually occurs due to perforation of a pre-existant diverticuli (erosion of the wall due to increased intraluminal pressure)
2
Q
An asymptomatic pt has a positive FOBT. Hx indicates he had a colonoscopy 2 years ago and was an unremarkable exam. Now what?
A
Check the hematocrit - This establish how much blood has been lost
The pt will most likely also need a repeat colonoscopy but this should be performed after the hematocrit results are obtained.
3
Q
Itchy, yellow, middle aged woman with positive anti-mitochondrial Ab.
A
Primary biliary cirrhosis
Bx - Periductal mononuclear infiltrate and bile duct destruction
4
Q
In a cirrhosis pt, the serum:ascites albumin ratio is?
A
Greater than 1.1
Cirrhosis causes portal HTN meaning that the ascites will have a lower quantity of albumin
5
Q
What is the most likely cause of passing bright red blood from the rectum in a otherwise asymptomatic pt?
A
- Diverticulosis
2. AVM (acute, chronic, or Fe deficient anemia)
6
Q
How do you manage thrombophlebitis?
A
- Doppler U/S to identify if deep thrombosis are present
- Warfarin
- CT of the abdomen (rule out malignancies (Trousseau syndrome, pancreatic most common))
Usually self limiting
7
Q
A pt with primary sclerosing cholangitis (PSC) presents with steatorrhea. Why?
A
Poor delivery of bile salts into the small intestine due to fibrosis of the intrahepatic and extrahepatic bile ducts. Eventually leads to deficiencies of fat soluble vitamins (nigh blindness)
8
Q
An asymptomatic pt with no alcohol hx presents with labs similar to cirrhosis. Dx?
A
Metabolic syndrome
(central obesity, insulin insensitivity, T2DM, hyperlipidemia)
Causes non-alcoholic steatohepatitis (NASH)
9
Q
Pt with telangiectasis + epistaxis + iron deficient anemia presents with a lower GI bleed. Family Hx of the same
A
Osler-Weber-Rendu syndrome (AKA hereditary hemorrhagic telangiectasia)
AD
Acute Tx = ablation
10
Q
A chronic alcoholic presents with hemoptysis but is negative for esophageal varicies. What’s the cause?
A
Splenic v. thrombosis
This vein runs posterior to the pancreas. Pancreatitis and hepatitis causes thrombosis
11
Q
Tx for HCV?
A
Peg-interferon (pegylated interferon) and Ribavirin
12
Q
How should pancreatic necrosis be managed?
A
Fluid resuscitation and abx
If this fails, pancreatic aspiration to rule out superinfection
If infected -> surgical debridement
13
Q
Potential complication of acute pancreatitis?
A
Adult Respiratory Distress Syndrome (ARDS)
Life threatening
Phospholipase is released -> circulates to the lungs and damages the alveolar capillary membranes
14
Q
Asymptomatic jaundice, direct hyperbili, elevated urinary coproporphyrins
A
Rotor syndrome
ar disorder of bilirubin storage
LFTs WNL
15
Q
What can elicit hepatic encephalopathy in a alcoholic?
A
Dehydration Infection Electrolyte abn (hypokalemia,metabolic alkalosis) Sedative GI bleeding
16
Q
What should be done in a HCV pt that has been receiving tx but develops advanced liver dz?
A
Evaluate for transplant
Severe dz = variceal hemorrhage, ascites, encephalopathy
17
Q
Ascites + mild diffuse abd pain + altered mental status + low grade fever. Dx?
A
Spontaneous bacterial peritonitis (SBP)
18
Q
What is the first step in management of spontaneous bacterial peritonitis?
A
Ascitic fluid, blood, urine should be cultured prior to starting abx
19
Q
Young healthy adult with RLQ pain, diarrhea, weight loss. Dx?
A
Crohn’s dz
Can also have extraintestinal manifestations -> aphthous ulcers and arthralgias
20
Q
How is Crohn’s diagnosed?
A
Hx/PE
Colonoscopy with entry into the terminal ileum
Findings - focal ulcerations with areas of normal mucosa (skip lesions)
Non-caseating granuloma formation
21
Q
Pt has anti HBs and Anti HBc. Dx?
A
Past Hep B infection
Ab against core protein is only seen in previous infection
Hbs Ag = active infection
22
Q
RF’s for gastric adenocarcinoma
A
H. pylori infection
Pernicious anemia
High intake of N-nitroso compounds (salted foods common in Asia)
Advanced age (70s, 80s)
23
Q
Tx for peptic strictures?
A
Esophageal dilation followed by chronic tx with a PPI to prevent recurrent
Strictures are caused by GERD
24
Q
Pt has macrocytic anemia and during Schilling’s test B12 is absorbed after IF administration. Dx?
A
Pernicious anemia
Autoimmune dz directed against the parietal cells
Bx -> atrophic gastritis
IV vit B12 for life
25
AutoAb in Primary biliary cirrhosis?
Antimitochondrial Ab
| Presents with pruritis
26
Ab in Autoimmune haptitis?
Anti-smooth muscle Ab
27
Steatorhea + on ileoscopy deep fissures and inflamation with strictures. Dx?
Crohn's dz
| Also presents with Fat and water soluble vit deficiencies, hypocalcemia, osteomalacia, and macrocytic anemia
28
Liver bx shows hepatocytes with moderate variation in number and shape, trabecular pattern, minimal connective tissue, and invading vascular channels. Dx and etiology?
Hepatocellular carcinoma
| In the US, associated with cirrhosis (viral or alcoholic), espcially hep b
29
Epigastric pain radiating to the back, + n/v + high lipase
Acute pancreatitis
| gallstones are the most common cause in those presenting with hx of biliary colic
30
1st line tx in hepatic encephalopathy?
Lactulose
Hyperosmotic agent
helps amonia stay in the gut and be secreted
31
RF's for acalculous cholecystitis
DM, long term critical illness, TPN
RUQ pain + leukocytosis, + elevated LFT's (esp alk phos)
Tx - Abx and chole
32
Mutation in APC gene
Familial adenomatous polyposis
| Types: Gardner syn, and Turcot syn
33
Key findings of Gardner syndrome
Numerous polyp's, colon cancer at 50, osteomas, epidermal inclusion cysts, hypertrophy of retinal pigment epithelium
34
Findings in Turcot syndrome
Numerous colonic polyps, colon cancer before 50, CNS tumors
35
Pt has odynophagia, malaise, and leukocytosis. dx?
Herpes esophagitis
| Tx with acyclovir
36
What is the initial management of mild ulcerative colitis?
Aminosalicylate enema or steroid foam
ASA enema is prefered over steroids for long-term management because it has fewer relapses
Treat resistant cases with prednisone
37
What should be considered in all pts with a fever and ascites?
Spontanous bacterial peritonitis
Occurs in 50% of hospitalized cirrhotic pts.
Dx via paracentesis with PMN>250 also serum/ascites albumin gradient >1.1
38
Best way to dx sphincter of Oddi dysfunction?
ERCP
39
Healthy pt <45 y/o with aymptomatic occasional hematochezia. Now what?
Anoscopy and flexible sigmoidoscopy
Ddx: polyp, fissures, distantly diverticulosis
Order colonoscopy if pt is 50+, or + FHx
40
RF's for squamous cell esophageal carcinoma (proximal to mid esophagus)?
Alcohol, achlasia, lye ingestion
41
Colonoscopic findings in IBS?
Normal mucosa
| *Key findings is pt does not have pain while sleeping
42
HIV pt with CD4<50 develops bloody diarrhea. Dx?
CMV colitis
| Tx with ganciclovir and HAART
43
Pt develops aymptomatic jaundice after a surgery.
Bening postop cholestasis
| Seen 2-10 days after long cardiothoracic or abd surgeries
44
Pt has had multiple bleeding ulcers x1 year despite taking a PPI. Suspicious for?
Zollinger-Ellison syndrome
Gastrin secretin tumor most likely in the pancreas
Surgical resection is curative
45
Elderly male pt with iron deficiency anemia
Colon cancer until proven otherwise
| Get a colonoscopy
46
Cause of dyspnea in the setting of cirrhosis
Hepatopulmonary syndrome
| Liver cannot clear pulmonary dilators
47
Macrocytic anemia + neurologic symptoms
B12 deficiency
| Multilobed PMN's with 5 or more segments
48
Middle aged woman with ithching, hepatomegaly, and Sjogren like symptoms
Primary biliary cirrhosis
| Tx with Ursodeoxuycholic acid (increases rate of intracellular transport of bile acids
49
Work up for dysphagia?
Barium swallow
50
Dysphagia pt has contrast entering a pouch posterior to the hypopharynx. Dx?
Zenker's diverticulum
It's a false diverticulum because it only involves the mucosa outpouching through the cricopharynx m.
Tx - surgery
51
What do you do for a pt with a duodenal ulcer -ve for urease that fails omeprazole?
Suspicious for zollinger-Ellison
| Stop the omeprazole and order a serum gastrin level
52
Low ceruplasmin is diagnostic for?
Wilson's dz
53
Bronzed diabetes
Hemochromatosis
| Sr ferritin is the appropriate screening test for iron overload
54
Tx for UC limited to the distal colon
```
Topical Mesalamine (enemas)
No need for systemic tx in proctosigmoiditis
```
55
How frequently should UC pts have colonoscopies?
8-10 years after diagnosis
| Then screening colonsocopy + bx annually
56
submucosal vessel within the GI tract that failed to branch into capillaries and penetrates the overlying epithelium causing upper GI bleeding
Dieulafoy lesion
Tx - banding or sclerosed
Suspect in a a pt w/ hematemesis, no RF's, and NL EGD
57
Best serologic marker for new onset of HBV?
IgM Anti-HBc
58
How do you work up an incidental finding of fatty infiltration of the liver (NAFLD)
Prothrombin time (PT)
Associated with IR or metabolic syndrome
Can progress to NSSH
59
Pt has flushing, diarrhea and elevated 5-hydroxyindoleacetic acid
Carcinoid syndrome
Generally caused by intestinal carcinoid tumor that has metastasized to the liver
Only develop syx after it has metastasized because the liver will clear the substances before it goes to systemic circulation
60
Acute hematemesis + facial edema + varices on EGD
Compression of the Superior vena cava (SVC syndrome)
| Most common cause is lung cancer
61
Infectious causes of bloody diarrhea
E. coli
Campylobacter
Shigella
Salmonella
62
Non bloody diarrhea + RLQ tenderness
Yersinia entercolitica
| Commonly confused with appendicitis but appendicitis tends to be constipation, n/v
63
How do you manage a pancreatic pseudocyst?
Asymptomatic - observe
| symptomatic - surgically drain (bloating is enough to be symptomatic)
64
What causes condyloma acuminata?
HPV 6 and 11
| Tx - freezing, trichloroacetic acid, surgical removal
65
When does carcinoid syndrome become symptomatic?
When the Small bowel tumor metastasizes to the liver
66
Autosomal dominant mutation in RET proto-oncogene
MEN IIa
| Pheochromocytoma, hyperparathyroidism, medullary thyroid carcinoma
67
H shaped vertebrae
Shrunken spleen
Unjongugated hyperbili
Sickle cell anemia
Gallstones also common (black pigment make of calcium bilirubinate)due to excessive Hgb breakdown
H shaped vertebrae due to bony infarctions
68
New onset ascities in a 50+ year old female with NL CMP
Concerning for ovarian malignancy
| Pelvic U/s
69
SLE pt presents with jaundice
Autoimmune hepatitis
+ ANA, anti-smooth muscle
Bx for dx
Tx - corticosteroids, azathioprine
70
All febrile pts with ascites must have a?
Abdominal paracentesis
71
RUQ + reflection of sounds waves on U/s
Emphysematous cholecystitis
Emergency, seen in pts with DM
Caused by gas forming bacteria
Tx - LCC + Iv Cipro and metronidazole
72
Watery/non bloody "traveler's diarrhea"
Enterotoxigenic E coli (ETEC)
| EIEC - causes dysentery (enteroinvasive)
73
How do you interpret the serum-to-ascities albumin gradient (SAAG)?
if >1.1 - portal hypertensive causes of ascites (Cardiac ascites, cirrhosis, Budd-Chiari)
if <1.1 - no portal HTN (TB, peritoneal carcinomatosis, pancreatitis, nephrotic syndrome)
SAAG = (Sr alb) - (Asc Alb)
74
Upper abdominal pain x 4 weeks
waxing and waning burning pain associated w/ nausea, awakens her at night
Bloating after meals
Immigrant
H. pylori associated PUD
dyspepsia, post prandial fullness, nausea
more common in low-income countries
Dx w/ EGD
75
IBD syx + ulcers in the mouth
Crohn dz
Chronic abd pain, diarrhea, weight loss, fistula/abscess formation, anemia, elevated inflammatory markers)
Can involve any part of the GI tract from mouth to anus (vs. UC that is only colitis)
76
Jaundice, anorexia, unintentional weight loss, dark urine, pale stool
Pancreatic cancer (most likely in the head)
Intra and extrahepatic biliary tract dilation due to back up of bile
Cancers in the tail of the pancreas typically present w/o jaundice
77
Ddx of steatorrhea
Pancreatic insufficiency
Bile salt related (Crohn, bacterial overgrowth, PBC, PSC, resection of ileum)
Impaired intestinal surgace (celiac, AIDS, Giardia)
Rare (Whipple, Zollinger-ellison, medication induced)
78
Pt w/ duodenal ulcers and jejunal ulcers has steatorrhea. Why?
Pancreatic enzyme inactivation and injury to the mucosal brush border
Zollinger-Ellison syndrome (gastrinoma)- suspect in Tx resistant GERD and ulcers distal to the duodenum
Increased stomach acid -> inactive pancreatic enzymes -> malabsorption
MEN 1 (PTH, ionized Ca2+, prolactin)
Dx - gastrin >1000 when gastric pH<4
79
Adult <35 w/ psych syx and Liver dz
Wilson's dz
psych - parkinsonism, dysarthria, choreoathetosis, ataxia, personality changes, depression
Copper accumulation
Dx - low ceruloplasmin and Kayser-Fleischer rings
Tx - chelators (D-penicillamine, trientine), po zinc
80
Chronic dysphagia, regurgitation of undigested food, difficulty belching, weight loss
Achlasia
Impaired peristalsis of the distal esophagus, failure of LES to relax
Dx - Manometry ("bird-beak")
Tx - myotomy, pneumatic balloon dilation, Botox, nitrates, CCB
81
steatorrhea + recent travel
Giardia
get a stool test
Tx - metronidazole
82
GI bleeds cause which type of anemia?
Iron deficiency
83
Steatorrhea + Fe deficiency anemia
Negative IgA anti-tissue transflutaminase Ab
Bx with villous atrophy
Celiac
IgA anti-endomysial and IgA anti-tissue transglutaminase are highly predictive, but if negative do not r/o celiac especially if bx is consistent
Celiac folks often also have IgA deficiency causing their serology to be negative
84
Crit care pt
| RUQ pain, Increased LFTs, leukocytosis, fever
Acolculous cholecystitis
Get gallbladder inflammation in critically ill
Dx - U/S, CT if needed
Tx - abx, cholecystostomy to drain, cholecystectomy once stable
85
Asian with chronic post prandial abd cramping and diarrhea
Lactose intolerance
Reduced lactase availability at the brush border
lactase -> glucose + galactase
86
What test can confirm lactose intolerance?
+ hydrogen breath test
+ stool test for reducing substances
Low stool pH
Increased stool osmotic gap
87
Sensitive and specific tool for dxing pancreatic carcinoma?
Abd CT
88
Most common malignancy of the liver?
metastasis from another primary cancer
89
What causes a pt to develop a Zenker diverticulum (pharyngoesophageal diverticulum)?
Motor dysfunction -> posterior herniation b/w fibers of the cricopharyngeal m.
Develops immediately above the upper esophageal sphincter
Dx - barium esophagram
Tx - surgical
90
Fever
Jaundice
RUQ pain
Acute cholangitis
91
3 causes of acute pancreatitis
```
Alcohol use
Gallstones
hypertriglyceridemia (>1000)
Medications (azathiprine, valproic acid, thiazides)
Infection (CMV)
Recent ERCP
Trauma
```
92
Sudden onset odynophagia and retrosternal pain that can sometimes cause difficulty swalling
Pill Esophagitis
| caused by Tetracyclines, KCl, Bisphophonates, NSAIDS
93
Young pt - frequent watery nocturnal diarrhea
| Colonoscopy - melanosis coli (dork brown discoloration w/ pale patches of lymph follicles
Laxative abuse (factitious diarrhea)
Hypokalemic, metabolic alkalosis d/t bicarb retention
+ stool screen for diphenolic or polyethanol glycol laxatives
94
Epigastric pain that improves w/ eating
Duodenal ulcer
Majority are caused by H. pylori or NSAIDS
Tx - abx + PPI
95
epigastric pain worse with eating
Gastric ulcer
| worse w/ eating d/t acid secretion
96
elevated LFT's
Encephalopathy
INR >1.5
Acute liver failure
Acetaminophen tox in a chronic alcohol user
Hypoperfusion
97
Why does acetaminophen toxicity also have ARI?
D/t renal tubular toxicity
98
Most common cause of colovesicular fistula?
Diverticulosis
99
Middle aged woman
Fatigue, pruritis, hepatomegaly
Elevated Alk phos
Primary biliary cholangitis
| Confirm dx - serum anti-mitochondiral Ab
100
Young pt w/ abd pain, bloody diarrhea, fecal urgency is likely to have?
IBD (UC or Crohns)
| Get abd Xray for toxic megacolon
101
Pt has asymptomatic elevated LFT's. What do you do first?
Ask more questions about Etoh, drug use, travel, transfussions, sexual practices
102
Conjugated hyper bili
| Marked elavation in alk phos
Biliary obstruction d/t pancreatic or biliary cancer
| other causes of obsturction - choledocholithiasis or benign biliary strictures
103
Conjugated hyperbili
| NL LFT's, AP
Inherited bilirubin disorders (ie. Dubin-Johnson syndrome)
104
Conjugated hyperbili
High LFT's
NL AP
Intrinsic liver dz (ie viral hepatitis, hemochromatosis)
105
Epigastric pain
| Amylase, lipase 3 x normal
Acute pancreatitis
| Does not require imaging to confirm
106
Chest pain
Wide mediastinum
Exudative pleural effusion w/ high amylase
```
Esophageal rupture (Boerhaave syndrome)
Ct with Gastrografin swallow study to confirm
```
107
Pancreatic calcifications on CT?
Chronic pancreatitis
108
Chest pain precipitated by emotional stress
Dysphagia
Regurgitation
Esophageal spasm
| Dx - Manometry
109
biliary colic persisting s/p cholecystectomy
Postcholecystectomy syndrome
Get Abd U/s followed by ERCP or MRCP
Can be biliary or extra biliary
110
Large volume diarrhea occuring during fasting or sleep
| Reduced stool osmotic gap
secretory diarrhea
d/t increased ion secretion
d/t infection of disorder of ion transport (CF)
111
Watery diarrhea with elevated osmotic gap
Osmotic diarrhea
112
EGD - multiple stomach ulcers, thickened gastric folds on endoscopy
Gastrinoma (Zollinger-Ellison syndrome)
| Fastring sr gastrin >1000 pg/mL
113
Acute cholecystitis is caused by gallstone impacting the?
Cystic duct
114
Why does TPN predispose to gallstones?
Gallbladder stasis
115
Liver Met. Primary source likely to be from?
GI tract
Lung
Breast
116
Risk factor for retroperitoneal hematoma?
Anticoagulation, even at therapeutic doses
117
Steatorrhea
| Impaired absorption of D-xylose
Dz of the intestinal mucosa (ie Celiac dz)
| Those that have malabsorption alone will have NL absorption of D-xylose
118
Upper GI bleed
| What change is seen on CMP?
Increased BUN/Cr
| d/t increased urea production from Hgb breakdown and increased urea reabsorption d/t hypovolemia
119
Porcelain gallbladder increases risk for?
Gallbladder adenocarcinoma
Tx - cholecystectomy
ON CT calcified rim in the gallbladder with a central bile filled area
120
Tx for toxic megacolon
Medical emergency
| Tx - prompt IV steroids, NG decompression, abx, fluids
121
Best test to Dx Zenker's diverticulum?
Contrast esophagram
122
Non alcoholic fatty liver dz is associated with?
Insulin resistance
123
Prevention of esophageal variceal hemorrhage in a cirrhosis pt?
Nonselective beta blockers (propanolol, nadolol)
124
Resuscitation in acute GI bleed < 7
Packed red blood cells
125
```
Older pt
Unexplained abd pain
weight loss
Food aversion d/t pain while eating
Bloating
```
Chronic mesenteric ischemia
Dx - with CT
Tx - risk reduction (tobacco), nutritional support, surgical revascularization
126
If you suspect c. diff
Send stool cultures and start metronidazole
127
AST/ALT > 1000
Hepatic encephalopathy
increased prothrombin time (INR>1.5)
Acute liver failure
| Need consideration for liver transplant
128
Macrocytic anemia w/ high homocysteine level
| NL Methylmalonic acid
Folate deficiency
129
Tx for new onset PBC
Ursodeoxycholic acid
Delays histologic progression, improves syx, possible survival improvement
advanced dz - liver transplant
130
Long standing GERd pt develops solid food dysphagia.
| Barium swallow - symmetric circumferential narrowing of the distal esophagus
Esophageal stricture
| RFs - GERD, radiations, systemic scleriosis, caustic ingestions
131
Diagnostic test for diverticulitis
CT w/ po and IV contrast
132
Best test to confirm acute HBV infection?
HBsAg and IgM anti-HBc
| Viral load is NOT collected in acute dx only chronic
133
PT < 40 with minimal rectal bleeding, no RF's for CRC
| Whatimaging do you order first?
Anoscopy - id if the source if hemorrhoids
| Get sigmoid or colonoscopy if no source is identified
