GI

Question 1

Diarrhea

Drug used to treat HAART associated diarrhea

Answer 1

Crofelemer

Question 2

Diarrhea

A patient has a mass in his liver and diarrhea what is the likely cause? What is the treatment?

Answer 2

E. Histolytica

Question 3

Diarrhea

What is the treatment for E. Histolytica

Answer 3

Metronidazole, then a lumenal agent - Paromomycin. Amebic colitis is treated first with a nitroimidazole derivative and then with a luminal agent to eradicate colonization. Paromomycin is safe, well tolerated, and effective in the treatment of intestinal amebiasis, including in patients with HIV infection. [73] Diloxanide is a dichloroacetamide derivative that is amebicidal against trophozoite and cyst forms of E histolytica. It is not available in the United States. Amebic liver abscess can be cured without drainage by using metronidazole. Treatment with a luminal agent should also follow. Disseminated amebiasis should be treated with metronidazole, which can cross the brain-blood barrier.

Question 4

Diarrhea

What is a new treatment for c-diff?

Answer 4

Fidaxomicin is the first in a new class of narrow spectrum macrocyclic antibiotic drugs

Question 5

Diarrhea

What is the initial treatment for c-diff if mild disease?

Answer 5

Metronidazole

Question 6

Diarrhea

What do you do if there is a recurrence after treatment of mild c-diff with metronidazole?

Answer 6

treat again for 10 days

Question 7

Diarrhea

What if there is a 3rd episode of recurrence of c-diff?

Answer 7

treat with oral vancomycin or fidaxomicin

Question 8

Diarrhea

What are the 2 most important risk factors for C. difficult antibiotic-associated colitis and how is it diagnosed?

Answer 8

Clostridium difficile Antibiotic-Associated Diarrhea Diagnosis C. difficile antibiotic-associated colitis is produced by two toxins, A and B. The most important risk factors are antibiotic use and hospitalization, but community-acquired infection is becoming increasingly common.

EIAs to detect the toxins are specific, but sensitivity using a single stool sample is 75% to 85%. PCR assays to detect the genes responsible for production of toxins A and B are more sensitive than EIAs.

The stool C difficile toxin test detects harmful substances produced by the bacterium Clostridium difficile (C difficile). This infection is a common cause of diarrhea after antibiotic use.

How the Test is Performed

A stool sample is needed. It is sent to a lab to be analyzed. There are several ways to detect C difficile toxin in the stool sample.

Enzyme immunoassay (EIA) is most often used to detect substances produced by the bacteria. This test is faster than older tests, and simpler to perform. The results are ready in a few hours. However, it is slightly less sensitive than earlier methods. Several stool samples may be needed to get an accurate result.

A newer method is to use PCR to detect the toxin genes. This is the most sensitive and specific test. Results are ready within 1 hour. Only one stool sample is needed.

Stool toxin first. PCR best.

Question 9

Diarrhea

What are the criteria for severe C. diff disease and how is the treatment different from mild disease?

Answer 9

Management of C. difficile infection is based upon disease severity. Severe disease is defined by any one of the following: • leukocytecount>15,000/μL • serumcreatininelevel≥1.5timesbaselinelevel • age>60years Hospitalized patients with known or suspected illness should be placed under contact isolation. Therapy Discontinue the offending antibiotic. Treat mild to moderate C. difficile infection with oral metronidazole. Treat severe infection with oral vancomycin. Severe disease associated with ileus may benefit from the addition of IV metronidazole and vancomycin enemas; select colectomy for very severe or complicated disease (e.g., toxic megacolon or severe sepsis). A first recurrence is treated in the same way as the initial episode, based on disease severity. A second relapse is treated with oral vancomycin given as a prolonged taper or pulse therapy for >6 weeks. Fecal microbiota transplant is used for patients with multiple relapses. Fidaxomicin, a nonabsorbable macrolide, is an alternative to vancomycin. ◆◆don’t be tricked • Donotobtainstoolculturesandcellculturecytotoxicityassays.

Question 10

Diarrhea

After returning home from South America, a patient presents with non-bloody diarrhea, abdominal pain, eosinophilia. what is the most likely diagnosis?

Answer 10

Strongyloides

Question 11

Diarrhea

A patient with AIDs and a low CD4 count presents with large volume diarrhea. Organisims are seen in a modified acid fast stain. What is the likely diagnosis?

Answer 11

Cryptosporidium

Question 12

Diarrhea

What is the treatment for cryptosporidium in AIDS

Answer 12

Nitazoxinide, also get CD4 up. worse disease under 100

Question 13

Diarrhea

C-diff produces and inflammatory diarrhea. What will you find in the stool?

Answer 13

Both RBCs and WBCs

Question 14

Diarrhea

What type of diarrhea is found with RLQ pain?

Answer 14

Yersinia Enterolitica

Question 15

Diarrhea

What are the criteria for severe C-diff infection? What is the treatment?

Answer 15

Management of C. difficile infection is based upon disease severity. Severe disease is defined by any one of the following:

• leukocytecount>15,000/μL

• serum creatinine level≥ 1.5 times baseline level

• age>60years

Hospitalized patients with known or suspected illness should be placed under contact isolation. Therapy Discontinue the offending antibiotic. Treat mild to moderate C. difficile infection with oral metronidazole. Treat severe infection with oral vancomycin. Severe disease associated with ileus may benefit from the addition of IV metronidazole and vancomycin enemas; select colectomy for very severe or complicated disease (e.g., toxic megacolon or severe sepsis).

Question 16

Diarrhea

Diarrhea associated with LLQ pain, diarrhea, blood and fever

Answer 16

Campylobacter jejuni

Question 17

Diarrhea

Patient gets sick 6 hours after eating potato salad at a picnic… what is the likely cause?

Answer 17

Staph toxin

Question 18

Diarrhea

Diarrhea and blisters 2 days after eating sushi?

Answer 18

Vibrio vulnificus

Question 19

Diarrhea

A nursery school teacher with diarrhea… most likely cause?

Answer 19

rotovirus

Question 20

Diarrhea

Diarrhea on a cruise-ship?

Answer 20

norovirus

Question 21

Diarrhea

Patient with bloody diarrhea and jaundice and RUQ pain/fever? What is the treatment?

Answer 21

Bloody diarrhea followed by RUQ pain, fever +/- Jaundice  Amebiasis( treatment metronidazoll + paromomycin)

Question 22

Diarrhea

Which agent causing diarrhea is associated with raw eggs?

Answer 22

Salmonella

Question 23

Diarrhea

What is this?

Answer 23

Giardia Trophozite

Question 24

Diarrhea

What are 3 categories of chronic diarrhea?

Answer 24

• Secretory
• Inflammatory -
• Osmotic - laxitives

Question 25

Diarrhea

When do you order stool samples in Acute Diarrhea?

Answer 25

The majority of acute diarrhea in developed countries is due to viral gastroenteritis or food poisoning and is self-limited.

A care-ful review of medication history (including nonprescription medications and supplements) is indicated to look for drugs that cause diarrhea. If diarrhea does not resolve in 1 week, evaluation is recommended with stool testing for common bacterial pathogens, including Clostridium difficile.

Do not be tricked into ordering stool samples for acute diarrhea less than one week.

Question 26

Diarrhea

77 y.o. male presents with diarrhea and LUQ pain that wakes him from sleep followed by diarrhea a few hours later. Unremarkable physical exam. H/O diabetes, CAD. Last year he had a normal colonoscopy. What is the likely diagnosis? What is the treatment?

Answer 26

Ischemic colitis, recent colonoscopy so none needed at this time. Treat with observation and fluids.

Question 27

Diarrhea

Watery diarrhea, bloating. flatulence and wt loss in a HIV positive patient. What special staining is required? What is the treatment?

Answer 27

Cyclosporidium - Watery diarrhea, bloating, flatulence, weight loss Modified acid-fast stain Trimethoprim-sulfamethoxazole

HIV patients have more severe illness with wasting

Question 28

Diarrhea

what is the definition of chronic diarrhea?

Answer 28

Chronic diarrhea is arbitrarily defined as lasting longer than 4 weeks and is often due to noninfectious causes, except for infection with

Giardia lamblia

. This diagnosis should be considered in patients with exposure to young children or potentially contaminated water (lakes and streams

Question 29

Diarrhea

ACP board basics 2015

Name some common medications that can lead to chronic diarrhea.

Answer 29

Medications are often overlooked as a cause of chronic diarrhea. Look for PPIs, magnesium-containing antacids, metformin, colchicine, antibiotics, and sorbitol (added as a sweetener to gum and candy).

Select colonoscopy for most patients with chronic diarrhea. Patients undergoing colonoscopy should have the terminal ileum viewed to assess for Crohn disease and undergo random biopsies of the colonic mucosa to assess for microscopic colitis.If the colonoscopy is nondiagnostic, a 48- to 72-hour stool collection with analysis of fat content measures the amount of diar-rhea and steatorrhea. Fat excretion above 14 g/d is diagnostic of steatorrhea. Patients with steatorrhea should undergo evaluation for small-bowel malabsorption disorders (e.g., celiac disease), bacterial overgrowth, and pancreatic insufficiency.Stool electrolytes (sodium and potassium) can be measured in liquid stool to calculate the fecal osmotic gap, which helps to diagnose osmotic diarrhea. he gap is calculated as 290 − 2

×

[Na

+

K]; an osmotic gap

>

100 mOsm/kg H

2

O indicates an osmotic diarrhea. A gap

<

50 mOsm/kg H

2

O indicates a secretory diarrhea. Measured stool osmolarity

<

250 mOsm/kg H

2

O suggests factitious diarrhea associated with chronic laxative abuse or adding water to the stool.Osmotic diarrhea is most commonly caused by lactase deficiency. Osmotic diarrhea is associated with eating, improves with fasting, and typically is not nocturnal. Secretory diarrhea is characterized by large-volume, watery, nocturnal bowel movements and is unchanged by fasting (see also Celiac Disease).

Question 30

Diarrhea

What is this and what is the treatment?

Answer 30

Microscopic Enterocolitis - treated with (1) if drug related - stop drug (2) bundesonide treatment (3) bismuth may be of some benefit?

Question 31

Diarrhea

What are some of the medications that can cause microscopic enterocolitis?

Answer 31

PPIs and NSAIDS may cause microscopic enterocolitis

Lansoprazole is a potent proton pump inhibitor that has been well tolerated with minimal serious adverse events. One of the most commonly reported side effects is diarrhea in 3–8% of study patients. During 1997, approximately 850 veterans at our institution had their proton pump inhibitor converted from omeprazole to lansoprazole because of a formulary change. A number of patients subsequently developed chronic watery diarrhea. While evaluating six of these patients, we discovered microscopic colitis that resolved with discontinuation of lansoprazole. The diarrhea was described as three to 10 loose, nonbloody bowel movements per day with some abdominal cramping. Colonoscopy in five patients and flexible sigmoidoscopy in one patient revealed normal colonic mucosa, but random biopsies all supported microscopic colitis (five cases of lymphocytic colitis and one case of collagenous colitis). Complete symptom resolution occurred in all patients within 4 to 10 days of discontinuing lansoprazole. In all patients, follow-up biopsies demonstrated normalization of the colonic histology. This is the first published case series of patients with microscopic colitis that correlated clinically and histologically with the initiation and discontinuation of lansoprazole.

Question 32

Diarrhea

Bloody diarrhea associated with raw meat?

Answer 32

e.coli 0157:H7

Question 33

Diarrhea

Hemolytic Uremic Syndrome is associated with which type of diarrhea and what is the mnemonic/features?

Answer 33

E-coli 0157:H7

F - Fever

A - anemia

T-thrombocytopenia

D-diarrhea

R-Renal Failure

Question 34

Diarrhea

TPP is associated with which type of bloody diarrhea and what are the features?

Answer 34

• E.Coli 0157
• F - fever
• A - anemia
• T - throbocytopenia
• R - Renal
• N - Neuro changes
• Ten percent of patients with enterohemorrhagic Escherichia coli O157:H7 (EHEC) colitis develop HUS or TTP.

Question 35

Colon Cancer

In the general population, when should colon cancer screening begin?

Answer 35

At the age of 50 and every 10 years thereafter

All adults ages 50-75 y using annual FOBT, flexible sigmoidoscopy every 5 y with FOBT every 3 y, or colonoscopy every 10 y

Question 37

Diarrhea

How do you treat moderate c-diff initially

Answer 37

Oral Vancomycin

Question 38

Colon Cancer Screen

A healthy fifty 55 year old never screened for colon cancer with no family history of cancer. USPSTF when to screen for ca colon?

Answer 38

Screening starts at fifty. The USPSTF 2016 does not differentiate between initial tests in terms of “best”

The bottom line:

A number of CRC screening tests are available, each with its own advantages and disadvantages. Less invasive tests usually need to be performed more often, such as once a year. Others, like colonoscopy, need to be done every 10 years. Talk with your doctor to figure out which test is right for you.

Stool-based tests include:

FOBT or fecal occult blood test (performed annually). In this test, which checks for blood in the stool, people gather samples from two or three consecutive bowel movements and pass them onto a doctor’s office or lab for testing. There is no prep, but people may need to avoid certain foods or medications beforehand. If blood is found, a colonoscopy will be needed to determine if it’s from cancer or some other cause.

FIT or fecal immunochemical test (performed annually). Similar to the FOBT, this test checks for blood in the stool in a different way. Multiple stool samples are required, but there are no drug or dietary restrictions. As with the FOBT, if blood is found, a colonoscopy will be required to determine the source.

FIT-DNA or multi-targeted stool DNA test (performed every one to three years). This test checks for blood in the stool as well as DNA mutations that might drive colorectal cancer. Available only by prescription, this kit comes via mail with tools to help people gather an entire stool, which is then mailed off for testing. If the test finds blood or DNA mutations, a colonoscopy will be needed.

“Direct visualization” tests take pictures of all or part of the colon, using a tiny camera or X-rays. They include:

Colonoscopy (performed every 10 years). In this 30-minute test, a doctor examines the entire colon and rectum using a tiny camera. Patients need to prep in advance by drinking a large amount of liquid laxative. A special diet may be required beforehand, as well. A sedative is used during the test, which is usually performed in a hospital outpatient setting or clinic. Unlike other tests, doctors can also remove or biopsy suspicious-looking polyps.

CT colonography (performed every five years). This test uses a CT or CAT scan (i.e. multiple X-rays) of the colon and rectum to look for polyps or cancer. It’s done quickly (it only takes 10 minutes or so), doesn’t require sedation and is somewhat less invasive, but prep is still required. People may also need to drink a “contrast” solution beforehand. If suspicious polyps or other areas are found, a colonoscopy will most likely still need to be used.

Flex sig or flexible sigmoidoscopy (performed every five years). This test allows a doctor to examine the rectum and part of the colon using a flexible lighted tube with a tiny camera on the end. It requires a prep of some sort so the colon is cleaned out and may also require a special diet beforehand. The test takes about 10 to 20 minutes and doesn’t necessarily require sedation (although it’s an option if you prefer). If a small polyp is found, the doctor can remove it. If it’s found to be cancerous (or pre-cancerous), a colonoscopy will need to be done to check the rest of the colon.

Combination tests:

Flex sig with FIT (performed every 10 years). A combination of the above test with a home FIT test that requires gathering samples from multiple stools. Again, if blood or suspicious polyps are found, a follow-up colonoscopy will be required.

Question 39

Colon Cancer Screen

What is Lynch Syndrome?

Answer 39

Lynch syndrome is diagnosed if a patient meets the criteria for HNPCC and also has an identified germline mutation in one of the four mismatch repair genes or the epithelial cell adhesion molecule (EPCAM). Lynch syndrome is also associated with an increased risk for extracolonic tumors, most commonly. If an inherited colon cancer syndrome is suspected, the patient and family members should be referred for genetic testing.

HNPCC(Lynchsyndrome),whichisanautosomaldominantdisorder

HNPCC(Lynchsyndrome),whichisanautosomaldominantdisorder Hereditary nonpolyposis colon cancer (HNPCC) diagnostic criteria include:

HNPCC(Lynchsyndrome),whichisanautosomaldominantdisorder Hereditary nonpolyposis colon cancer (HNPCC) diagnostic criteria include:

• ≥3 relatives with colorectal cancer
• onerelativeafirst-degreerelativeoftheothertwo • ≥2 successive generations affected
• onecancerdiagnosedbeforeage50years

Question 40

Colon Cancer Screen

Lynch Syndrome - When to start screening and how often?

Answer 40

Risk Profile When to Initiate Colonoscopy Screening

HNPCC risk Every 1-2 years starting at age 20 or 25 years, or 10 years earlier than the age of youngest person in family diagnosed with colon cancer

Question 41

colon cancer Screen

First degree relative was diagnosis with colon cancer at age 30

irst-degree relative diagnosed with an adenomatous polyp or colon cancer at age ≤60 year

Answer 41

Age 40 years, or 10 years younger than the earliest diagnosis in the family – every 5 years

Two second-degree relatives with adenomatous polyp Age 40 years or 10 years younger than the earliest diagnosis in the family – or colon cancer at any age every 5 years

Two first-degree relatives with colon cancer

Age 40 years, or 10 years younger than the earliest diagnosis in the family – every 3-5 years

Question 42

H pylori

treatment for Hpylori

Answer 42

PPI and 2 antibiotics - amoxicillin and clarithyomicin X7 -14 days

Question 43

PUD

Most common causes of PUD

Answer 43

H Pylori and NSAIDS

Question 44

H pylori

25 year old male had duodenal ulcer with bleeding, treated with PPI and 10 day course of clarithromicin and amoxicillin. what is the test for cure?

Answer 44

Don’t use antibody test. will remain positive

Urea breath test or stool antigen 4 weeks post treatment

Question 45

Diarrhea

Features of Hereditary Colon Cancers:

• HNPCC
• Gardener’s Syndrome
• Familial Polyposis

Answer 45

Early Screening is recommended for patients with familial syndromes. The following is a partial list of hereditary syndromes that commonly appear on tests:

Familial adenomatous polyposis

Autosomal Dominant

Polyposis disorder that requires prophylactic colectomy,

Duodenal and peri-ampullary cancers are the second leading cause of cancer deaths in this group.

Gardner syndrome, which is a type of familial adenomatous polyposis with extra-intestinal manifestations, including osteomas, duodenal ampullary tumors, thyroid cancers, and medulloblastomas

HNPCC (Lynch Syndrome)

Autosomal Dominant disorder

Hereditary nonpolyposis colon cancer (HNPCC) diagnostic criteria include

Greater or ≥3 relatives with colorectal cancer


One relative a first- degree relative of the other 2

≥2 successive generations affected


One cancer diagnosed before 50 years of age.

Lynch syndrome is diagnosed if a patient meets the criteria for HNPCC and also has an identified germline mutation in one of the four mismatch repair genes or the epithelial cell adhesion molecule (EPCAM). Lynch syndrome is also associated with an increased risk for extra-colonic tumors, most commonly endometrial. If an inherited colon cancer syndrome is suspected, the patient and family members should be referred for genetic testing.

Question 46

colon cancer

Colon cancer screening

Answer 46

Screening recommendations and frequency of screening are based on consensus opinion.
Oncology

ColonCancerScreening
Risk Profile When to Initiate Colonoscopy Screening
Average risk

• Age 50 years – every 10 years to age 75 years (other screening modalities are available)
• First-degree relative diagnosed with colon cancer at Age 50 years – every 10 years to age 75 years (other screening modalities are age ≤60 years available)
• First-degree relative diagnosed with an adenomatous polyp or colon cancer at age ≤60 years –>Age 40 years, or 10 years younger than the earliest diagnosis in the family – every 5 years
• Two second-degree relatives with adenomatous polyp–> Age 40 years or 10 years younger than the earliest diagnosis in the family – or colon cancer at any age every 5 years
• Two first-degree relatives with colon cancer. Age 40 years, or 10 years younger than the earliest diagnosis in the family – every 3-5 years
• HNPCC risk
  
  • Every 1-2 years starting at age 20 or 25 years, or 10 years earlier than the age of youngest person in family diagnosed with colon cancer
• Familial adenomatous polyposis risk
  
  • Age 10-15 years (annual sigmoidoscopy)
• Pancolitis (ulcerative colitis or Crohn disease) 8-10 years after initial diagnosis – every 1-2 years

Question 47

Pancreatitis

Ransons Criteria for Pancreatitis

Answer 47

Pancreatitis: Ranson criteria for pancreatitis: at admission“GA LAW” (GA is abbreviation for the U.S. state of Georgia):
Glucose >200
AST >250
LDH >350
Age >55 y.o.
WBC >16000
Pancreatitis: Ranson criteria for pancreatitis: initial 48 hours“C & HOBBS” (Calvin and Hobbes):
Calcium < 8
Hct drop > 10%
Oxygen < 60 mm
BUN > 5
Base deficit > 4
Sequestration of fluid > 6L

Question 48

Diarrhea

32 year old 6 mo history of difficulty swallowing. feels as if something stuck in his throat. Endoscopy shows mulitple rings with white specks. no strictures. mucosa is friable. Biopsy shows inflamation and eosinophils in lamina propria. What is the diagnosis? what is the treatment?

Answer 48

eosinophilic esophagitis. Treat with topical (swallowed) steroids.

Seen in Young adults. extreme dysphagia with food impactions.

Question 49

Diarrhea

1. most likely diagnosis? chronic diarrhea, iron def anemia, vesicular rash on elbows and sacrum, weight loss.
2. what test?
3. what are they at risk for?
4. what is the rash called?

Answer 49

1. Celiac Disease
2. anti-tissue transglutamase antibody or antigliadin
3. or upper endoscopy with jejunal biopsy showing decreased villi/decreased finger projections
4. increase osteoporosis, decrease vitamin D, small bowel lymphoma, decreased folate
5. dermatitis hermatiformis

Question 50

Dysphagia

Intermitant dysphagia to solids verses progressive dysphagia solids… Possible diagnoses, treatment

Answer 50

Solids only think mechanical

intermitant—–> Lower esophageal web

(Patient can’t swallow spit after eating steak) may use glucogon in ED to relax muscles and also call GI Consult)

Solids - Progressive think cancer (older, weight loss)

or peptic stricture

Question 51

Dysphagia

Dysphagia to solids and liquids

Intermitant verses progress diagnoses

Answer 51

Progressive - Scleroderma or achalasia

Intermitant - Diffuse Esophageal Spasm, Nut cracker esophagus

Question 52

Gastroparesis

67 year old presents with chronic nausea, vomiting, early satiety. diabetes and previous bariatric surgery. What is the likely diagnosis? Endoscopy showed retained food. What is the test to diagnosis?

Answer 52

Gastroparesis. perfered diagnositic test Gastric Emptying Scan preferred study. causes: diabetes, gastric surgery, amyloidosis, scleroderma.

Question 53

Diarrhea

What is the treatment for gastroparesis?

Answer 53

small, frequent meals, prokenitic medicines - metocloprmide –>1-10% of irreversable tardive dyskenesia

Oral erythomycin - tachyphlylaxis

May need percutaenous jejunostomy for weight loss or repeated hospitalizations