GI Flashcards
green vs black stones: etiology
green: cholesterol (5 Fs)
black: hemolysis
Cholelithiasis: management
if surgical candidate: cholecystectomy
if not surgical: ursodeoxycolic acid
Cholecystis: DX
RUQ US (pericholecystitic fluid and thickened GB wall +/- gallstones)
If this is negative, but high suspicion, get HIDA
Choledocolithiasis: DX
RUQ US showing obstruction
if this is negative but high suspicion, get MRCP
Choledocholithiasis: complications (2)
hepatitis
pancreatitis
Cholangitis: Path and TX
gallstone in CBD + infection
TX: first emergent ERCP, give antibx (for GNR and anarobes) on the way to OR
Cholangitis: antibx options
cipro + metronidazole or ampicillin-gentamicin + metronidazole or pip-tazo (but try to avoid)
Esophagitis: causes (5) and definitive diagnosis
Pill-induced Infectious Eosinophilic Caustic gErd
DX: EGD with biopsy always
Esophagitis: clinical features
odynophagia and dysphagia
Pill-induced esophagitis: speicifc meds (4)
NSAIDs
anitbx (specifically tetracycline)
Bisphosphonates
HAART
Infectious esophagitis: causes (4) and clinical features
Candidia: oral thrush (treatment with oral fluconazole, as in vaginal candidiasis)
HSV (oral lesions, ulcers in multiple stages of healing; tx with val/acyclovir)
CMV (no typical appearance, get biopsy, tx with gangcyclovir)
HIV (look for other oppurtunistic infections; start on HAART)
Eosinophilic esophagitis: risk factors and biopsy findings
risk factors: atopy, allergies, and asthma triad
Dx: EGD with biopsy showing >15 eos per HPF
Tx: first trial on PPIs, if this fails, use aerosolized steroids
Corkscrew esophagus =
diffuse esophageal spasm
Esophagus that looks like beads on a string
Barium swallow showing narrowed lumen: diff dx
schatskis ring vs cancer
get biopsy
IDA and dysphagia
plummer vinson syndrome
NOTE: esophageal webs have risk of transforming into cancer, so F/u with EGDs regularly
Stricture vs cancer: distinguishing featrues
stricture: barium swallow showing symmetric luminal narrowing
cancer: assymmetric luminal narrowing
NOTE: EGD with Bx is definitive
Peptic ulcer disease: etiologies (5) and appearance/clinical features
H. pylori (especially suspect if duodenal ulcer, single)
NSAIDs (shallow and multiple)
cancer (heaped margins and necrotic center)
curling ulcer (think burn victims)
cushing ulcer (increased ICP with brain injury, steroids, and ventilators)
ZES
Multiple ulcers refractory to PPIs, and diarrhea
ZES
Triple therapy for H. Pylori
clarithromycin
amoxicillin (mtz if penicillin allergy)
PPI
Diagnosis of ZES
(1) gastrin level (>1600 diagnostic, <250 nl, otherwise can do secretin stim test)
(2) if gastrin level concerning, f/u with somatostatin receptor scintography (SRS)
H. Pylori infection: most accurate vs initial test
initial: serology
most accurate: EGD with biopsy
H. Pylori infection: test for eradication
stool antigen
Chronic abdominal pain after eating in someone with DM
gastroparesis
DM with neuropathy of vagus nerve (most also have peripheral neuropathy)
Habitual marijuana use with vomiting every so often
cyclic vomitting syndrome
maybe from THC withdrawal
Cyclic vomitting syndrome: TX
stop THC
use metaclopramide or erythromycin (IV, if severe)
Signet ring cells
gastric adenocarcinoma
Gastroparesis: TX in chronic vs acute disease
stable disease: metaclopromide (PO)
flares:
erythromycin (IV)
NOTE: domperidone not used in US, but sometimes is obtained for compassionate use
Definition of acute vs chronic diarrhea
acute: <2weeks duration
chronic: >4weeks duration
Perceived change in quality of stool or amount or frequency OR objectively elevated amount (>200grams)
Enterotoxic diarrhea: pathogens (6)
C. diff ETEC vibrio cholera staph aureus B. cereus giardia
Invasive diarrhea: pathogens (
Salmonella Shigella EHEC (O157-H7) Campylobacter Ameba histolytica
Association with a. histolitica invasive diarrhea
immunocompromise, specifically HIV/AIDS
W/u invasive diarrhea
postive for stool WBC/lactoferrin and RBCs
Get stool cx and colonoscopy
if cx positive, worry about infection
if colonoscopy positive, worry about IBD
C. diff infection: best test
c. diff NAAT
Severe C. diff: TX
Severe C. diff is when there is leukocytosis, megacolon, or azotemia
PO vancomycin (intraluminal protection) AND IV metronidazole (extraluminal)
HUS: TX
plasma exchange
Stool osmolar gap =
measured osmoles (290) - calculated osmoles (2x [Na + K])
Secretory vs osmotic/malabsoprtive diarrhea: stool osmolar gap
secretory: <50
osmotic/malabsorptive: >100 (other things in stool that bring Na and K down and increase gap)
Bilirubin and ALP in cholecystits vs choledocholithiasis/cholangitis
cholecystis: mild elevation in total bili (1-4) and direct bili (d/t passage of sludge/pus in the CBD); nl ALP
choledocholithiasis: elevated total bili and ALP
Best imaging test for trauma pt with gross hematuria, difficulty urinating, and blood at the meatus/suprpubic pain
restrograde cystourethrogram
Best imaging test for person with blunt genitourinary trauma who is HDS
CT abdomen w/contrast
brick-red urate crystals in an infants diaper
sign of mild dehydration
may be associated with breasfeeding failure jaundice and unconjugated hyperbilirubinemia (from increased enterohepatic circulation of bili)
Breast milk jaundice: clinical features
starts age 3-5 days, peaking at 2 weeks; adequate breastfeeding and normal exam with no dehydration and no issues with feeding that would point to breast feeding jaundice
Increased gastric residual volume, vomiting, and abdominal distension in a preterm neonate
NEC
Get abdominal Xray looking for pneumatosis intestinalis
gold standard imaging test for malrotation in an infant
upper GI contrast series study
Typical age for midgut volvulus
<1 month old
Colonoscopy showing cyanotic mucosa and hemorrhagic ulcerations
ischemic colitis
SAAG >1.1
portal HTN (from rCHF or cirrhosis)
SAAG <1.1
malignancy
pancreatitis
nephrotic syndrome
TB
Increased permeability of capillaries
Low grade fever, abdominal discomfort, and AMS in pt with cirrhosis and ascites
SBO
Test abnormality in SBO
Reitan trail test (timed connect the numbers test) detects subtle mental status changes in SBO
Marked pruritus and elevated total bile acids and/or aminotransferases in pregnancy =
intrahepatic cholestasis of pregnancy
NOTE: jaundice is unusual in this condition and requires further w/u (evaluation for acute fatty liver of pregnancy)
Diagnostic criteria for SBO (2)
positive ascites fluid culture (often GN organisms like E coli and klebsiella)
+
Neut count >250
SBO: TX
empiric: 3rd generation cephalosporins (cefoxatime)
ppx: fluoroquinolones
Elevated ALP in patient with UC should raise suspicion for
PSC
Best diagnostic imaging test fgor acute diverticulitis
CT abdomen with contrast
Best diagnostic tests for acute hep B infection
HBsAg and IgM anti-HBc
Does secretory diarrhea wake someone up from sleep?
yes (this distinguishes it from osmotic diarrhea)
Pathogenesis of gilbert syndrome
AR or AD mutation causing a decrease in UDP-glucuronosyltransferase activity and increase in unconjugated bili (<3) during times of stress
Duodenum absorbs ____(4)
folate, iron, calcium, and carbs (FICC)
Terminal ilium absorbs ____(3)
bile acids
fat soluble vitamins (ADEK)
vitamin B12
100g fat test for malabsoprtion postive finding
> 14 g/day in stool over 72 hours
Location of highest involvement in celiac disease
proximal duodenum
iron deficiency, osteoporosis
Malabsorption +brain/joint/lymph node involvement and PAS positve organisms
T whippeli infection
whipples disease: tx
TMX-SMP
doxycycline
Older pt with pmh of constipation with postprandial LLQ pain relieved by BM
diverticular pain (spasms)
Imaging to r/o perforation or obstruction
upright KUB
Diverticulitis: TX
Cipro + metronidazole
gent/amp + metro
pip tazo (dont pick this though as is too broad and expensive)
Primary prophylaxis for esophageal variceal hemorrhage
endoscopic variceal ligation
or
propranolol/nadolol (non-selective beta-blockers)
D-xylose evaluates absorption in which part of the small bowel?
small bowel
Drug used to treat colon cancer
beveciumab (VEGF-i)
3 options for colon cancer screening in asymptomatic population
colonoscopy q10 or sigmoidoscopy q5y + FOBTq3yr or FOBTq1yr
HNPCC cancer and family associations
Colorectal cancer
Eendometrial cancer
Ovarian cancer
3,2,1 (3 cancers in family, 2 generations, 1 premature death from cancer)
Peutz-Jeugers:cancer location
SMALLBOWEL, do EGD
not crc
Causes of cirrhosis
Viral hep B/C Wilsons Hemochromatosis Alpha 1 antitrypsin PSC PBC EtoH NASH/NAFLD Something else
Hep C from ___
IVDU
Hep B from____
sex
First and best tests for Wilsons
1st: slit lamp
best: liver biopsy showing increased copper
Mainstay therapy for wilsons vs hemochromatosis
wilsons: penacillamine
hemachromatosis: phlebotomy
Best test to diagnose alpha-1 antitrypsin and findings
biopsy (shows PAS positive macrophages, same as in whipples disease)
PSC: diagnostic tests
MRCP (beads on a string)
ERCP (onion skin fibrosis)
PSX: TX
best: transplant
while waiting can give urso-deoxycolic acid
PBC: Imaging findings
NOTHING
Get biospy if supsect PBC
variceal bleeding: ppx and acute tx
acute: octreotide
ppx: nadolol, propronalol
Ppx for SBO: indications and drug
indications: SBO once before
or total protein <1.0
TX: fluoroquinolone
Hepatocellular cancer: diagnostic w/u
Sceening with RUQ US and AFP
diagnosis with triple phase CT
AVMs assoicated with
aortic stenosis
Conditions in which there is elevated amylase
conditions that involve vomiting
gallbladder inflammation
pancreatitis (since not as specific, get either lipase or amylase-p)
Most sensitive test for prognosis in acute pancreatitis
BUN
Early complications of acute pancreatitis
ARDS
HypoCa (caponification)
pleural effusion
ascites
SIRs following acute pancreatitis
infection, get biopsy and start with meropenam until cultures and sensitivities come back
SBO or abdominal fullness after acute pancreatitis =
pancreatic pseudocyst
Intrahepatic causes of unconjugated hyperbilirubinemia
criggler-Nijar (really bad form and Gilbert-type form) and
Gilberts
Intrahepatic causes of conjugated hyperbilirubinemia
Dubin-Johnson (black liver)
Rotors
Hep C: TX
Protease inhibitors (direct-acting antagonist) i.e. borceprevir
Carcinoid syndrome: TX
octreotide
Hepatorenal syndrome: TX
somatostatin (octreotide), midodrine
Name a somatostatin drug
octreotide
Orthodeoxia found in ___
hepatopulmonary syndrome
orthodeoxia = hypoxia upon sitting upright
Causes of larger than nl AST/ALT ratio (3)
EtoH
NASH
Medications that can cause liver dysfunction
Bilirubin and ALP in early PBC are ____
normal (bili) and elevated (ALP)
NOTE: early PSC is the same
PBC: complications
cirrhosis
osteoporosis
PBC: physical exam finding
xanthelasma/xanthoma
PBC and PSC: TX
cholestyramine or ursodeoxycolic acid
Tests that you can do with lacose intolerance (4)
Hydrogen breath test (positive)
Stool test for reducing substance (positive)
stool pH (low)
stool osmotic gap (high)
