GI Flashcards
Diagnosis of achalasia
Manometry is the most accurate test and will show failure of the LES to relax
Barium esophagram will show a birds beak
Upper endoscopy is useful to rule out malignancy
Achalasia treatment
Pneumatic dilation, myomectomy or surgical sectioning is more effective but more dangerous
Botox injections – last 3 to 6 months
For cancer, what is never the most accurate test?
Radiologic tests, For example, esophageal cancer needs an endoscopy and biopsy
Best test for diffuse esophageal spasm and nutcracker esophagus
Manometry, which will show a different pattern of abnormal contraction and each of them
Corkscrew appearance when spasm is occurring
Treated with CCBs and nitrates, similar to Prinzmetal angina, PPIs can help
Dysphagia and HIV patient with CD4 less than 100, what to do next?
Empirically start flucanazole, assuming esophageal candidiasis
If no improvement, upper endoscopy with biopsy and if large ulcerations it’s CMV treat with ganciclovir, if small – HSV, acyclovir
How to detect rings and webs
Barium studies of the esophagus
Zenker is diagnosed with? Treatment?
Barium studies, surgery
Not NG tube or endoscopy, dangerous for these people they may perforate
How to scleroderma present, management?
Reflux, inability to close the LES, manage with PPI’s
Manometry for
Achalasia, spasm, Scleroderma
Stress ulcer prophylaxis indicated in
Mechanical ventilation, burns, head trauma, coagulopathy
Cancer and gastric versus duodenal ulcers
4% of gastric, virtually no duodenal
Therapy for H. Pylori
PPI + clarithromycin + amoxicillin
If refractory: metronidazole + tetracycline
If gastric ulcer, repeat ulcer to exclude malignancy
Test of cure: stool antigen or breath test
Non ulcer dyspepsia management
If under 45, empiric with PPI
If over 55, endoscopy
Also if dysphagia weight loss, anemia
Gastrinoma is often associated with?
Diarrhea since the acid inactivated lipase
If gastrinoma + hypercalcemia?
MEN 1: hyperparathyroidism
Once gastrinoma confirmed, next best step is to?
Exclude mets: CT/MRI of abdomen, if normal then somatostatin receptor scintigraphy + endoscopic US
GIB treatment
IVF
transfuse PRBCs when HCT below 30 in elderly/CAD pts
If drops below 20-25 in others
FFP
platelets if below 50k + bleeding
Varices: Octreotide decreases portal pressure, banding, TIPS, propranolol/nadolol, abx to prevent SBP
Treatment for Whipple
Tropical sprue?
Ceftriaxone followed by Bactrim
Tropical sprue: bactrim, tetracycline
Distinction between chronicle pancreatitis and celiac
Celiac will have iron deficiency as it requires an intact bowel wall to be absorbed, but does not need pancreatic enzymes
In contrast vitamin B12 needs both
Diagnosis of chronic pancreatitis
Abdominal XR, CT
Most accurate: secretin stim test: healthy will release large volume HCO3- rich fluid
IBS treatment
Hyocyamine, Diclocyamine
TCAs, loperamide, lubiprostone, linaclotide
Treatment of IBD
5-ASA agent: mesalamine Azathioprine, 6-MP to wean of steroids Calcium, vitamin D Perianal Crohns: cipro and metro Anti-TNF: infliximab if severe Surgery especially for UC
Diverticulitis treatment
Cipro + Flagyl Augmentin Zosyn Timentin Carbapenem NPO Surgery if no response, recurrent infections, perforation, abscess, fistula, obstruction
HNPCC screening
FAP?
Begin at 25, scope every 1-2 yrs
FAP: sigmoidoscopy at 12 every year
paracentesis should be performed if?
new-onset ascites, abdominal pain/tenderness, fever
SAAG over 1.1
think “dilute” ascites fluid- pushed out: portal HTN, CHF, hepatic vein thrombosis, constrictive pericarditis
SAAG less than 1.1
think leakage (“exudate” like): infections (except SBP), cancer, nephrotic syndrome?
MC etiologies of SBP
treatment
E. coli, S. pneumo, NOT anaerobes
treat with cefotaxime or ceftriaxone
frequently recur, prophylax with norfloxacin or bacterium if low albumin in ascites
all variceal bleeding with ascites needs SBP ppx
treatment of hepatorenal syndrome
somatostatin (octreotide), midodrine
when to think hepatopulmonary syndrome
orthodexia
hypoxia with sitting upright
normal bilirubin with elevated alk phos, xanthomas, osteoporosis, think? how to diagnose? tx?
PBC
most accurate test is liver biopsy, most accurate blood test: AMA Ab
bilirubin and IgM levels elevate LATER
treat with urso
IBD, pruiritis, ^alk phose, GGTP, bilirubin, think?
most accurate test?
PSC
MRCP*/ERCP(generally don’t need intervention) is best test, shows narrowing/beading/strictures in biliary system
biopsy not needed (only cause of cirrhosis that does not need biopsy)
treat with urso or cholestyramine, does NOT improve with IBD resolution (colectomy)
mild ^AST, Alk phos, fatigue, joint pain, ED, amenorrhea, skin darkening, DM, cardiomyopathy, think? what infections are more common? dx?
hemochromatosis
pituitary involvement- amenorrhea/ED
infections with Vibrio vulnificus, Yersina, Listeria (feed on iron)
dx liver biopsy after ^iron/ferritin, but abdominal MRI and HFE (C282y) genetic testing may spare need for liver biopsy
EKG may show condition defects, echo CM
hemochromatosis treatment
phlebotomy
if are refractory or are anemic and have hemochromatosis from over transfusion (thalassemia), iron chelation therapy: deferoxamine (IV/IM), deferasirox, deferiprone (oral)
treatment for hepatitis B
any 1 of the following: (combo tx is not more effective)
adefovir, lamivudine, telbivudine, entecavir, tenofovir, interferon
treatment of hepatitis C
acute: interferon, ribavirin, and either telaprevier or boceprevir
chronic: combo of ledipasvir and sofosbuvir (genotype 1)
sofosbuvr and ribavirin (genotypes 2, 3)
+ interferon, ribavirin, boceprevir when treatment fails
combo therapy is best, follow with PCR viral load
cirrhosis, hepatic insufficiency, psychosis, tremor, ataxia, seizures, coombs negative hemolytic anemia, RTA or nephrolithiasis, think?
Wilsons
best initial test: slit lamp for Kayser-Fleischer rings
LOW ceruloplasmin
liver biopsy shows ^copper
most accurate test: abnormally increased copper excretion AFTER penicillamine (chelates)
other tx: Zn: interferes with absorption, trientine: chelates
autoimmune hepatitis markers
+ANA, +anti-liver-kidney microsomal Abs, ^IgG, +anti-smooth muscle Abs
treat with prednisone +/- azathioprine
