GI Flashcards
_______ is the idiopathic loss of the normal neural structure of the lower esophageal sphincter (LES)
Achalasia
Pathology of achalasia
In achalasia, these inhibitory neurons have been lost, as well as the ability to relax the LES.
Secondary causes of achalasia
Chagas disease, gastric carcinoma, or diseases that can infiltrate into the area, such as lymphoma.
SSx of achalasia
Achalasia presents with progressive dysphagia to both solids and liquids simultaneously and can have regurgitation several hours after eating.
________ is very accurate and shows dilation of the esophagus, which narrows into a “bird’s beak” at the distal end.
Barium esophagography
Achalasia
_____is very accurate and shows dilation of the esophagus, which narrows into a “bird’s beak” at the distal end.
Barium esophagography
Achalasia
The most accurate test overall (gold standard) is esophageal________
manometry. Manometry shows increased lower esophageal (LES) resting pressure.
Achalasia
The best initial therapy is________
pneumatic dilation or surgery. Pneumatic dilation should be effective in 80–85% of patients
Achalasia
_______injections into the LES are used in those patients not willing to undergo pneumatic dilation,
or in whom it has failed.
Botulinum toxin
Achalasia
______ will relapse in 6–9 months, and all patients will need reinjection after 2 years
Fifty percent
If both pneumatic dilation and botulinum toxin
injections fail, then surgical_______ is performed
myotomy
Esophageal cancer is linked to the synergistic, carcinogenic effect of alcohol and tobacco use for cases of _______ in the proximal two-thirds of the esophagus
squamous cell cancer
Adenocarcinoma is found in the distal third of the esophagus and is associated with
__________ and _______
long-standing gastroesophageal reflux disease and Barrett esophagus
The rate of development of cancer from Barrett esophagus is between _________ per year.
0.4 and 0.8%
T or F
Squamous and adenocarcinoma are now of equal frequency.
T
Esophageal CA. Five-year survival is ________
5–20%.
Esophageal CA
Chemotherapy with a _______ is combined with radiation to control locally metastatic disease
5-fluorouracil-based chemotherapy
As many as 80 to 90% of patients with scleroderma will develop diminished esophageal peristalsis from the _______
atrophy and fibrosis of the esophageal smooth muscle.
Scleroderma (Progressive Systemic Sclerosis)
The most accurate diagnostic test is ______
motility studies
Scleroderma (Progressive Systemic Sclerosis) Tx
Therapy is with proton-pump inhibitors, such as omeprazole. Metoclopramide is a promotility agent that has some modest efficacy
Diffuse Esophageal Spasm and Nutcracker Esophagus
Barium studies
Barium studies may show a “corkscrew”’ pattern at the time of the spasm
Diffuse Esophageal Spasm and Nutcracker Esophagus
Tx
Treatment is with calcium-channel blockers, such as nifedipine, and nitrates
________is more common and leads to intermittent dysphagia and is not associated with pain. It is also more distal and located at the squamocolumnar junction proximal to the lower esophageal sphincter
Schatzki’s ring
_____ is more proximal and is located in the hypopharynx. The dysphagia is sometimes with liquids as well
Plummer-Vinson syndrome (PVS)
Dx of PVS and Schatzkis ring
Both disorders are best diagnosed with a barium swallow or barium esophagram.
Treatment. Plummer-Vinson syndrome may respond to treatment of the
iron deficiency. Both are treated with dilation procedures
__________ is the outpocketing of the posterior pharyngeal constrictor
muscles at the back of the pharynx
Zenker diverticulum
CI in pts with Zenker
Endoscopy and the placement of nasogastric tubes are contraindicated because
of the risk of developing perforation of the pharynx
Patients with Zenker diverticulum are
treated with_______
surgical resection.
______ is a nontransmural tear of the lower esophagus that is related to repeated episodes of retching and vomiting
Mallory-Weiss syndrome
SSx of Mallory-Weiss syndrome
It presents with painless upper GI bleeding.
Dx of Mallory-Weiss syndrome
These patients are diagnosed by direct visualization on upper endoscopy.
_____ is the most common reason for epigastric tenderness and pain
Pancreatitis
_____ is associated with epigastric tenderness in <20% of patients.
Ulcer disease
________ a functional disorder in
which there is persistent pain in the epigastric area but all the tests are found to be normal.
nonulcer dyspepsia,
H. pylori can be diagnosed with noninvasive means, such as
serology, urea breath testing, and
stool antigen detection.
When testing for eradication, do not use ELISA. Use _______
breath test or stool antigen
T or F
calciumchannel blocking agents and nitrates also lower the sphincter pressure
T
GERD
The most accurate diagnostic test is a ________ but this is only necessary when the patient’s presentation is equivocal in nature and the diagnosis is not clear
24-hour pH monitor,
A small number of persons, usually______, will not respond to PPIs and will need to undergo surgery to tighten the sphincter.
<5%
GERD
______ should only be used if the patient has very mild, intermittent symptom
H2 blockers
GERD
Indication for surgery:
- Refractory side effects with PPIs, e.g., headaches, diarrhea
- No response to PPIs
Pathogenesis of Barrett
After several years of GERD, the epithelium of the lower esophagus undergoes histologic change from a normal squamous epithelium to a columnar epithelium.
Patients with Barrett esophagus should have a repeat endoscopy every _____years
to see whether dysplasia or esophageal cancer has developed
2 to 3
Patients with low-grade dysplasia
should undergo repeat endoscopy in ______months to see if the lesion has progressed or resolved.
3 to 6
Patients with high-grade dysplasia should have a ______ because of its very high rate of progression to invasive esophageal
carcinoma
distal esophagectomy or an endoscopic mucosal resection
Barrett
The usual rate of progression to cancer is about ____ per year
0.5%
PUD
T or F
Tobacco and alcohol cause PUD
F
Tobacco and alcohol use can delay healing and are associated with the development
of gastritis, but they do not cause ulcers
Strongest RF for PUD
The strongest causal relationship for the development of ulcers is the use of NSAIDs, Helicobacter pylori infection, cancer of the stomach, Zollinger-Ellison syndrome, Crohn’s disease, burns, head trauma, and prolonged intubation and mechanical ventilation.
The presumptive mechanism of the formation of stress ulcers from burns and head trauma is that there is an ________
intense vasoconstriction of the vasculature that supplies the gastric mucosa, leading to the sloughing of these cells and ulceration
The 3 stimulants to the production of acid from the _______
parietal cells are gastrin, acetylcholine, and histamine
_____ is produced by G cells in the
stomach, and its release is stimulated by distention of the stomach, the presence of amino acids, and vagal stimulation.
Gastrin
the single most important stimulant to gastrin release is ______
distention of the stomach.
____ is released by enterochromaffin-like cells present in the same glandular elements of the stomach that have the parietal and chief cells.
Histamine
___ release pepsinogen, which is converted
to pepsin by the acid environment of the gastric lumen.
Chief cells
___ directly stimulates the parietal
cells to both release acid and potentiate the effects of acetylcholine and gastrin on the parietal cells.
Histamine
_____ is the excessive production and release of gastrin from G cells.
Somatostatin is the counterbalance to this system.
Zollinger-Ellison syndrome
_____ inhibits the release of gastrin
and histamine, as well as having a direct inhibitory effect on the production of acid from the parietal cells.
Somatostatin
_____ is released from the S cells of the duodenal lining.
Secretin
The main stimulant to the release of secretin is the presence of _____
acid in the duodenum.
_____ inhibits the production of gastrin, as well as stimulates pancreatic and biliary bicarbonate production and release
Secretin
80–90% of duodenal ulcers and 70–80% of gastric ulcers are associated with _____
H. pylori
Traditionally, ____ have been associated with pain on eating, and ____ were thought to be relieved by eating
gastric ulcers
duodenal ulcers
Ulcer disease is best diagnosed with ____
upper endoscopy
PUD
In those age >45–55 or those with alarm symptoms (weight loss, anemia, heme-positive stools, or dysphagia), _____should be performed.
endoscopy
PUD
The advantage of both _____ and _____ methods is that they have the same sensitivity as serology and are able to easily distinguish new versus old disease. When H. pylori has been treated, both become negative
breath testing and stool antigen detection
PUD (H. pylori)
The _____is performed to
see if the organisms present in the biopsy specimen can produce urease, demonstrating the presence of the bacterium.
CLO
Tx of H. pylori
Use a PPI combined with clarithromycin and amoxicillin.
Tx of H. pylori
The other 2 choices of antibiotic are _______
tetracycline and metronidazole
The PPI/clarithromycin/amoxicillin regimen should be effective in ____
of patients. Duration of therapy is _____
> 90%
10 to 14 days
In those who fail therapy, a _____should be performed to see if the reason for failure
was the inability to eradicate the organism
urea breath test
H. pylori Tx
If the organism was eradicated and the ulcer persists, recurs, or worsens, the
patient may need evaluation for____
Zollinger-Ellison syndrome.
Indications for surgery in PUD:
- UGI bleeding not amenable to endoscopic procedures
- Perforation
- Refractory ulcers
- Gastric outlet obstruction (can change endoscopic dilation)
What type of gastritis?
Caused by alcohol, as well as NSAIDs, Helicobacter, head trauma, burns, and mechanical ventilation. Also MC
Type B
______ gastritis is from atrophy of the gastric mucosa and is associated with autoimmune processes, such as vitamin B12 deficiency. Also linked to diminished gastric acid production and achlorhydria
Type A
________
leads to metaplasia as well as possible dysplasia and then to gastric cancer
MALT (mucosal-associated lymphoid tissue)
Most patients with gastritis present with ______
asymptomatic bleeding.
Vitamin B12 deficiency and pernicious anemia
are initially diagnosed with a ______
low vitamin B12 level and an increased methylmalonic acid
The diagnosis of pernicious anemia is confirmed by the presence of ____ and ______
antiparietal cell antibodies and anti-intrinsic factor antibodies
_____ is hypergastrinemia caused by cancer of the gastrinproducing cells
Zollinger-Ellison syndrome (ZES)
Half of these gastrinomas are located in the ____, and a quarter are located in the ______
duodenum
pancreas
Association of ZES
A small percentage (<20%) are associated with multiple endocrine neoplasia type 1 (MEN-1) or parathyroid,
pituitary, and pancreatic tumors
More than 95% of patients with ZES present with _____
ulcer disease
WHy is there steatorrhea in ZES
Steatorrhea occurs because lipase is inactivated by the large volume of acid passed into the duodenum.
Although an elevated gastrin level is indicative of ZES, it is critical to remember
that all patients on ______have high gastrin levels
H2 blockers or PPIs
Another way to diagnose ZES is to find an ________
elevated gastric acid output while concurrently finding an elevated gastrin level
Other causes of increased gastrin are
- Pernicious anemia
- Chronic gastritis
- Renal failure
- Hyperthyroidism
After confirming a diagnosis of gastrinoma, the most important step is to determine if the
lesion is________
localized or metastatic
A nuclear test, ______ is 90% sensitive for the detection of metastatic disease.
somatostatin-receptor
scintigraphy,
______ also called delayed gastric emptying, is a disorder that results in
delayed movement of food from the stomach to the small intestine.
Gastroparesis,
Gastroparesis
_____ can also weaken the musculature of the bowel wall
Electrolyte problems with potassium, magnesium, and calcium
Tx of Gastroparesis
Treatment is with agents that will increase motility of the stomach, such as erythromycin
or metoclopramide
This is an increasingly rare disorder because of the rarity of the necessity for
surgery in the treatment of ulcer disease
Dumping Syndrome
Dumping syndrome is caused by 2 phenomena.
• First, there is the rapid release of hypertonic chyme into the duodenum, which acts as
an osmotic draw into the duodenum, causing intravascular volume depletion.
• Next, there is a sudden peak in glucose levels in the blood because of the rapid release
of food into the small intestine. This is followed by the rapid release of insulin in
response to this high glucose level, which then causes hypoglycemia to develop
When all the causes of epigastric pain have been excluded and there is still pain, the diagnosis is
functional or nonulcer dyspepsia.
functional or nonulcer dyspepsia Tx
If there is no response to anti-secretory therapy with a PPI, you can try to treat H. pylori by adding clarithromycin
and amoxicillin.
Treating H. pylori will improve symptoms in another 10–20% of patients.
Similar Sx of IBD
Both CD and UC are idiopathic disorders of the bowel associated with diarrhea,
bleeding, weight loss, fever, and abdominal pain
Imaging of IBD
Both are most accurately diagnosed with endoscopy and sometimes with barium studies, “string sign” on small bowel follow through after barium meal in CD.
______ more likely to be associated with a palpable abdominal mass because it
has granulomas in the bowel wall that are transmural in nature.
Crohn’s disease
CD is not necessarily continuous, and one hallmark of the disorder is that there are ______or areas of normal tissue in between the areas of disease.
“skip lesions,”
UC is limited exclusively to the ______
large bowel
______has no skip lesions, no fistula
formation, and no oral or perianal involvement. It is more likely to cause bloody diarrhea.
UC
Both forms of IBD can lead to colon cancer after ______ of involvement of the colon
8–10 years
Complications of Crohn’s disease are calcium
oxalate kidney stones, diarrhea, and cholesterol gallstones
________are associated with CD, and _________ is associated with UC.
Anti– Saccharomyces cerevisiae antibodies (ASCA)
antineutrophil cytoplasmic antibody (ANCA)
Prothrombin time may be prolonged in CD because of______
vitamin K malabsorption
Kidney stones form more often in CD because _______
the fat malabsorption results in a low calcium level and an increased absorption of oxalate, which forms kidney stones
_____ derivatives are the mainstay of therapy for IBD in all of its forms
Mesalamine
______ is a form of mesalamine released in both the upper and lower bowel; hence, it is
used in CD
Pentasa
____is a form of mesalamine released in the large bowel, and it is most useful
for UC
Asacol
_____ is used exclusively for rectal disease
Rowasa
The difficulty with _____ is that the high load of sulfa delivered causes a number of adverse effects, such as rash, hemolysis, and allergic interstitial nephritis.
sulfasalazine
Acute exacerbations of IBD are treated with ______
high-dose steroids
Azathioprine and 6-mercaptopurine
are associated with_______but are still used on a long-term basis to try to keep patients off steroids
drug-induced pancreatitis,
Ciprofloxacin and metronidazole are used for CD in those with ____
perianal disease
_____ is used for CD in those who form fistulae or have disease refractory to the other forms of therapy
Infliximab
_____are other forms of mesalamine that are only active in the colon and are used occasionally
Balsalazide and olsalazine
Surgery is curative in ____; almost 60% of patients will require surgery within 5 years after diagnosis due to refractory symptoms or severe disease
UC
The most common causes of infectious diarrhea are _______ and ____especially
in patients with sickle cell and achlorhydria.
Campylobacter and Salmonella,
Ingestion of refried Chinese food and the
spores. Short incubation period (1–6 hours)
Bacillus cereus
Reactive arthritis, Guillain-Barré syndrome.Most common cause of bacterial gastroenteritis
Campylobacter
Found in HIV-positive patients with
<100/mm3 CD4 cells
Cryptosporidia, Isospora
Associated with the ingestion of contaminated hamburger meat. The organism can release a Shiga toxin, provoking hemolytic uremic syndrome
E. coli 0157:H7
The ingestion of unfiltered water, as on a
camping trip or in the mountains, or in
drinking fresh lake water.
Can also simulate celiac disease in terms
of causing fat and vitamin malabsorption if it is not eradicated.
Giardia
Ingestion of chicken and eggs, dairy products
Salmonella
Patients who ingest contaminated fish
experience vomiting, diarrhea, flushing, and
wheezing within minutes of eating it.
Scombroid
______ can mimic appendicitis. Also
common in people with iron overload, e.g.,
hemochromatosis.
Yersinia
Ingestion of raw shellfish, such as mussels,
oysters, and clams. Typically presents as severe systemic gastroenteritis in patients with underlying disease (esp. chronic liver disease)
Vibrio parahaemolyticus
Also in raw shellfish, but has a particularly
high incidence in people with underlying liver
disease or disorders of iron metabolism
Vibrio vulnificus
Ingestion of dairy products, eggs, salads.Short incubation period (1–6 hours)
Staphylococcus aureus
2–6 hours after ingestion of large reef fish
(grouper, red snapper, and barracuda).
Also neurological symptoms → paresthesia,
weakness, and reversal of heat and cold
Ciguatera-toxin
____are only found when there has been invasion of the intestinal mucosa, as in
dysentery, which is a bacterial infection of the bowel, producing diarrhea and bloody stool.
Fecal leukocytes
Invasive organisms need 24 to 36 hours to produce their effect and never give blood in the stool within the first few hours of their ingestion. (The only exception is the protozoan _____, which can give blood or white cells in stools.)
Entamoeba histolytica
The most definitive test for these bacterial
organisms is a _______
stool culture.
Cryptosporidiosis is diagnosed with a unique test, a _______
modified acid-fast test.
_____is best diagnosed with an ELISA stool antigen test. A single stool antigen test has 90% sensitivity. Three stool ova and parasite examinations have only 80% sensitivity.
Giardia
The best empiric therapy for infectious diarrhea is ciprofloxacin or the other ________
fluoroquinolones ± metronidazole
Scombroid poisoning is treated with _______
antihistamines, such as diphenhydramine
A newer agent for Giardia is______ which is effective in a single dose
tinidazole,
Cryptosporidiosis is treated with ____although it has limited efficacy
nitazoxanide,
The truly effective therapy for cryptosporidiosis is to ____
raise the CD4 count to >100/ mm3 with antiretrovirals
Nitazoxanide is superior to______ for cryptosporidium.
paromomycin
______ refers to a spectrum of diarrheal illnesses caused by the toxins produced by this organism, including severe colitis with or without the presence of pseudomembranes
Clostridium difficile diarrhea (C. diff)
T or F
Any antibiotic can lead to diarrhea with C. diff, although antibiotics that are broad spectrum are more likely to do so
T
_______diarrhea is largely a nosocomial disease and is the most frequent cause of diarrhea in hospitalized patients
C. diff
Recent meta-analysis suggests a significant association between C. difficile and the use of ______
proton pump inhibitors
During the past few years, there has been renewed interest in C. diff diarrhea reflecting
a form of disease that is more frequent, more severe, and more refractory to standard
treatment. These observations are explained by the presence of a new strain of C. diff,
designated ______which produces more toxins A and B and is resistant
NAP-1,
Both C. difficile toxins A and B exhibit potent ________ and ______ that are
responsible for the clinical manifestations
enterotoxic and cytotoxic effects
The clinical manifestations of C. diff may vary from ______
mild diarrhea to fulminant colitis.
C. difficile colitis
The newest preferred method of diagnosis is the ________which may include the real-time polymerasechain reaction (PCR) or loop-mediated isothermal amplification test, both of which detect the toxin A and B genes responsible for the production of toxins
nucleic acid amplification (LAMP,
loop-mediated isothermal amplification) assay,
C. difficile colitis
_______ is the drug of choice along with discontinuation of antibiotics (if
feasible) and supportive therapy.
Metronidazole
Oral vancomycin is reserved for the following conditions:
- Failed therapy with metronidazole
- Organisms resistant to metronidazole
- Patient is allergic to or cannot tolerate metronidazole
- Patient is pregnant or a child age <10
- Patient is critically ill
C. difficile colitis
If the symptoms resolve but there is a recurrence (~ 30% in some studies), then ________
retreat with metronidazole
_______ seems to decrease the number of episodes of recurrent C. difficile colitis
Fidaxomicin
Lactose intolerance is perhaps the single most common potential cause of diarrhea
because of the enormously high prevalence of_________
lactase deficiency
ssx of lactase deficiency
The diarrhea produced is associated with gas and bloating, but never has blood or leukocytes in it
dx of lactase deficiency
A precise diagnosis can be established by finding an increased stool osmolality and increased osmolar gap
The osmolar gap means that the difference
between the osmolality measure in the stool and the osmolality calculated from the sodium and potassium levels is_______
> 50 mOsm/kg.
Other causes of an increased stool osmolar gap are ____
magnesium and polyethylene glycol in the stool, also nutrient malabsorption → pancreatic insufficiency, celiac sprue, and
bacterial overgrowth
Rx of SSx of lactase deficiency
should occur within 24 to 36 hours.
Rx of SSx of celiac disease,
take weeks after stopping the ingestion
of gluten-containing foods.)
_______ is an idiopathic disorder in which there is increased frequency of the normal peristaltic and segmentation contractions of the bowel. Pain is often relieved by a bowel movement.
IBS
SSx of IBS
Twenty percent of patients with IBS have constipation only. A large number have diarrhea alone or diarrhea alternating with constipation. Everyone has pain.
Dx criteria for IBS
• Pain relieved by a bowel movement or by a change in bowel habit (e.g., when you
develop diarrhea, the pain goes away)
• Fewer symptoms at night
• Diarrhea alternating with constipation
There is no clear definitive therapy for IBS. All patients should be placed on a ______
highfiber diet in an attempt to increase the bulk of the stool
IBS
Those with diarrhea-predominant disease
should receive antidiarrheal agents, such as ______
loperamide or diphenoxylate.
MOA of anti-spasmodics for IBS
The presumptive mechanism of these agents is that they will relax the bowel wall musculature and diminish the pain
IBS Resistant cases may respond to?
TCA
MOA of TCA for IBS
The presumptive mechanism is that the tricyclics are anticholinergic and will relax the bowel.
A newer agent is ______, which is used in constipation-predominant IBS.
tegaserod
tegaserod cx
diarrhea
_____ is used in diarrhea-predominant IBS, and it slows motility
Alosetron
Bronchial carcinoids are rare but are
highly symptomatic because _____
the serotonin produced from a bronchial carcinoid does not get detoxified in the liver and is released directly into the circulation
Carcinoid syndrome
A rash may develop from______which is a direct result of the carcinoid.
niacin deficiency,
Serotonin and niacin are both produced from _______ If there is an overproduction
of serotonin, it produces a tryptophan deficiency, which leads to a deficiency of ________
tryptophan.
niacin.
Endocardial fibrosis also occurs because of a constant exposure of the right side of the heart to the serotonin. This leads to __________
tricuspid insufficiency and pulmonic stenosis.
Carcinoid syndrome
Therapy is generally based on controlling the diarrhea with _____which is a
somatostatin analog.
octreotide,
Iron malabsorption occurs if there is involvement of the ___where iron is normally
absorbed
duodenum
Iron deficiency anemia is evident in all patients with _______
celiac sprue.
_______is from damage or loss of the mucosal surface of the terminal ileum.
Vitamin B12 malabsorption
All of the malabsorption syndromes present with chronic diarrhea. The only unique feature of celiac disease is ________
dermatitis herpetiformis
In addition to the usual presentation of a fat
malabsorption, ______ is characterized by dementia (10%), arthralgias (80%), and ophthalmoplegia.
Whipple disease
Celiac disease is first diagnosed by testing for the presence of ____ and _____
antiendomysial and antitransglutaminase antigliadin antibodies
Dx of Celiac
The most accurate test is a small bowel
biopsy, which shows_______
flattening of villi.
Celiac
Just removing gluten (wheat, rye, and oats) from the diet is not a very accurate way of establishing the diagnosis because the ________
circulating antibodies will continue to be present for weeks after stopping the ingestion of gluten
Chronic Pancreatitis
The most accurate test, although rarely done, is a ________
secretin test, or finding a low trypsin leve
_____was performed in the past to help distinguish between celiac disease and chronic pancreatitis.
d-xylose testing
If there is no absorption of d-xylose, it means there is a_______
bowel-wall abnormality
d-xylose was absorbed and excreted in chronic pancreatitis, but not in ______
celiac disease, Whipple disease, or tropical sprue, in which there is a bowel-wall abnormality
______is malabsorbed in pancreatic insufficiency and celiac disease. Pancreatic enzymes are necessary to absorb this
Vitamin B12
The single most sensitive test for Whipple’s disease is a_______
polymerase chain reaction (PCR) of the bowel biopsy.
A positive Tropheryma whippelii biopsy shows ________
foamy macrophages that are PAS positive.
______ is used when celiac patients have dermatitis herpetiformis.
Dapsone
Chronic pancreatitis can be managed by ______
orally replacing all the deficient enzymes
Tropical sprue is treated with ______
trimethoprim/sulfamethoxazole or doxycycline for 6 months
_______ is associated with GI lymphoma and adenocarcinoma; patients are at risk for adenocarcinoma of the intestine.
Celiac disease
Celiac sprue is associated with _____
(10-15% of cases); it is unclear whether therapy with gluten-free diet decreases incidence of lymphoma
lymphoma (enteropathy-associated T cell lymphoma)
Diverticulosis is presumably caused by a _______
lack of fiber in the diet to give bulk to stool.
Diverticula are more common on the left in
the______ but bleeding occurs more often from diverticula on the right because of _____
sigmoid,
thinner mucosa and more fragile blood vessels
Diverticulitis is confirmed by ______
CT scanning
_____ and _______are relatively contraindicated in diverticulitis because there is a slightly higher risk of causing perforation.
Barium studies and endoscopy
Diverticulitis is treated with antibiotics such as ______ and ______
ciprofloxacin and metronidazole
The most common cause of constipation is generally a ________
lack of dietary fiber and insufficient fluid intake
Drugs causing constipation
Calcium-channel blockers, oral ferrous sulfate, hypothyroidism, opiate
analgesics, and medications with anticholinergic effects, such as the tricyclic antidepressants, all cause constipation.
Drug treatment of constipation includes _______
milk of magnesia, cascara, bisacodyl, and docusate (Colace).
The lifetime risk of colon cancer is ____.
> 6%
Diets that are high in _____ and _____lead to an increased risk for colon cancer, and smoking also increases the risk for colon cancer
red meat and fat
Patients present with heme-positive, brown stool and chronic anemia when the cancer is in the _______
right side of the colon
______are more often associated with symptoms of obstruction and with narrowing of stool caliber.
Left-sided lesions and cancer of the sigmoid
colon
Endocarditis by _____ and ____ is often associated with colon cancer
Streptococcus bovis and Clostridium septicum
Colon CA
_________ is clearly the most accurate diagnostic test. _______ will only
reach the lesion within the distal 60 cm of the colon.
Colonoscopy
Sigmoidoscopy
Cancer that is localized to the _____, ______ and _______
can easily be resected and cured.
mucosa, submucosa, and muscularis layers
Colon CA
Widespread disease is treated with chemotherapy. The mainstay of chemotherapy for GI malignancies, such as colon cancer, is ______
5-fluorouracil (5FU).
Colon CA
Treatment for a single liver metastatic lesion is _______
surgical resection
The standard screening recommendation for colon cancer is annual fecal occult
blood testing or colonoscopy every ____
10 years.
False-positive stool guaiac tests can be caused by_______
aspirin, NSAIDs, red meat, and poultry.
False-negative guaiac tests can be caused by ______
vitamin C
If adenomatous polyps have been found on a previous colonoscopy, repeat colonoscopy in
______
3–5 years
In those who have a family history of colon cancer, screening should begin at _______
age 40, or 10 years earlier than the family member, whichever is younger
Hereditary Nonpolyposis Syndrome (Lynch Syndrome
By definition, the syndrome consists of having 3 family members in at least 2 generations with colon cancer
Hereditary Nonpolyposis Syndrome (Lynch Syndrome
CA associated with it:
There is a very high incidence of ovarian and endometrial cancer in this
syndrome as well. Up to 30% of patients develop endometrial cancer.
Hereditary Polyposis Syndromes gene defect
The adenomatous polyposis coli gene (APC) confers 100% penetrance for the development of adenomas by age 35 and of
colon cancer by age 50.
Flexible sigmoidoscopy for familial adenomatous polyposis should be done ________
every 1 to 2 years beginning at age 12.
Hereditary Polyposis Syndromes: if polyp found, what to do?
As soon as polyps are found, a colectomy should be performed, and a new rectum should be made from the terminal ileum
By contrast, juvenile polyposis syndrome confers about a ______risk of colon cancer
10%
polyps of the juvenile polyposis syndrome are ______
hamartomas
_____ is another polyposis syndrome with hamartomas that gives only a very
slightly increased risk of cancer compared with the general population. These polyposis syndromes can present with rectal bleeding in a child
Cowden syndrome
______ is the association of colon cancer with multiple, soft-tissue tumors, such
as osteomas, lipomas, cysts, and fibrosarcomas
Gardner syndrome
Gardner syndrome
The osteomas have a particular predilection
for the _____
The osteomas have a particular predilection
for the mandible.
_______is the association of hamartomatous polyps in the large and small
intestine with hyperpigmented spots
Peutz-Jeghers syndrome
Peutz-Jeghers syndrome
Most common presentation is with abdominal pain due to_______
intussusception/bowel obstruction.
______ is simply the association of colon cancer with central nervous system
malignancies
Turcot syndrome
There is an association of endocarditis from ______ and colon cancer;
Streptococcus bovis
If the patient has a history of cirrhosis of the
liver, or if there is occult cirrhosis (as found in a long-term alcoholic), _____ should be
added to this initial management plan to decrease portal hypertension
octreotide
The hematocrit should be maintained at ______in older patients and those who may have coronary artery disease
≥30%
_____will also stop acutely bleeding varices,
but there is a much higher complication rate later on, such as stricture formation
Sclerotherapy
If banding is not effective in stopping an acutely bleeding esophageal varix, then _______
TIPS (transjugular
intrahepatic portosystemic shunting) should be performed.
The most common, long-term complication
of TIPS is worsening of _______
hepatic encephalopathy.
A______ to tamponade the site of bleeding in the stomach or esophagus is rarely
used and is only a temporary bridge to surgery.
Blakemore tube
____ is a nonselective beta-blocker used in the long-term management of portal
hypertension to decrease the frequency of bleeding
Propranolol
upper GI bleeding is defined as
bleeding occurring proximal to the_____ which anatomically separates the duodenum from the jejunum.
ligament of Treitz,
Lower GI bleeding is most commonly caused by _______
diverticulosis, angiodysplasia (also know as
AVM or vascular ectasia), hemorrhoids, cancer, and inflammatory bowel disease.
In upper GI bleeding, occult blood–positive brown stool can occur with as little as______
5 to 10 mL of blood loss
Melena develops when at least _____ of blood have been lost.
100 mL
_____ is defined as a >10-point rise in pulse when the patient goes from the supine to the
standing or sitting position. It is also defined as a >20-point drop in systolic blood pressure on a change in position.
Orthostasis
______ is the most accurate test to determine the etiology of both upper and
lower GI bleeding.
Endoscopy
A nuclear bleeding scan can detect low volume bleeds ______
0.1–0.5 mL/min.
_____ however, is useful in extremely high-volume bleeding in which so much blood is coming out that endoscopy cannot see the source. It may then be used prior to either embolization of the site of the bleeding or hemicolectomy.
Angiography,
Despite all of these methods, an etiology of GI bleeding cannot be determined in about 5% of patients. This is often because ____
the upper endoscope only goes as far as the ligament of Treitz, and the lower endoscope only reaches just past the ileocecal valve.
The newest modality to visualize the small bowel is_______, in which a patient swallows a capsule with an electronic camera that can transmit thousands of images to a receiver near the patient
capsule endoscopy
______ is a CT scan used to try to detect cancer without the need of endoscopy
Virtual endoscopy
The majority of cases of pancreatitis are due to _______
alcoholism and gallstones.
Drugs causing ACUTE PANCREATITIS
Medications such as pentamidine, didanosine (DDI), azathioprine, and sulfa derivatives,
like sulfamethoxazole/trimethoprim and thiazide diuretics
How does hyper TG cause pancreatitis
Hypertriglyceridemia, in which elevated triglycerides are broken down to fatty acids,
causing inflammation of the biliary tract and eventual pancreatitis
How does ERCP cause pancreatitis
Endoscopic retrograde cholangiopancreatography (ERCP), presumably because of back pressure from injection of the contrast material into the ductal system
Premature activation of _______ while still in the pancreas (common pathway of most causes of pancreatitis). This results in autodigestion of the pancreas
trypsinogen into trypsin
In acute panc
What is a more Sp marker of dse?
Lipase is more specific to the pancreas than is the amylase
Acute Panc
An increased severity of disease and a worse prognosis are indicated by the _____
presence of decreased serum calcium, elevated white cell count, hypoxia, and elevated glucose, LDH, and AST
The glucose will go up in the most severe forms of pancreatitis because of _____
the loss of both endocrine function and insulin production.
The most accurate test to determine the severity of pancreatitis is the _____ which is more accurate than a sonogram for the presence of inflammation, as well as for detecting necrosis, pseudocysts, abscesses, and the presence of ductal stones
CT scan,
The single most accurate test for the detection of biliary and pancreatic ductal pathology is the________
ERCP
ERCP is sometimes necessary to _____
remove a stone in the pancreatic duct or to dilate a stricture.
When pancreatitis is very severe, such as when there is >30% necrosis visible on the CT scan, the risk of ________ increases
infected and hemorrhagic pancreatitis markedly increases
______ develop only 2 to 4 weeks after the episode of pancreatitis
Pseudocysts
Pseudocysts should be drained if there is ________. Asymptomatic pseudocysts do not need to be drained unless there is concern.
pain, fistula formation, and rupture or if the pseudocyst is expanding in
size
Signs of Severe Necrotizing Pancreatitis
______ blue discoloration around umbilicus
→ due to hemoperitoneum
_______ bluish purple discoloration of the flanks → tissue catabolism of
Hb.
Cullen sign:
Turner’s sign:
when at least ______of liver function has been lost, the synthetic capacity of the liver is diminished
70 to 80%
Dx of SBP
A total white cell count >500/mm3 or the presence of >250/mm3 neutrophils are the criteria to determine the presence of infection
_____ and _____ are the drugs of choice for SBP and albumin infusion decreases risk of hepatorenal syndrome
Cefotaxime and ceftriaxone
- When this gradient, or SAAG, is >1.1, __________ is generally the cause.
- When the SAAG is <1.1, it means the ascitic fluid albumin level is high. _________generally give a SAAG <1.1.
portal hypertension, as from cirrhosis,
Cancer and infections
Encephalopathy is managed with ________ a nonabsorbed disaccharide that
bacteria metabolize in the colon, making it more acidic. This converts the NH3 to NH4
+, or ammonia to ammonium.
Ammonium is not absorbed very well, and this leads to an overall increased excretion of ammonia from the body.
neomycin or lactulose,
Although vitamin K is often given because of the elevated prothrombin time, it is not effective because _____
the liver is not able to synthesize clotting factors,
Primary biliary cirrhosis has a strong association with other autoimmune diseases, such as _______
Sjögren syndrome, rheumatoid
arthritis, and scleroderma
MC Sx of PBC
The most common symptoms are fatigue and pruritus
MC labs of PBC
The most common abnormality is an elevation
of alkaline phosphatase and gamma glutamyl transpeptidase (GGTP).
PBC
The most specific blood test is the ____
antimitochondrial antibody
Mx of PBC
Bile acid medication, such as _____, are used with variable success
ursodeoxycholic acid and cholestyramine
This is an idiopathic disorder of the biliary system most commonly associated
with inflammatory bowel disease (IBD)
Primary Sclerosis Cholangitis
PSC
Cancer of the biliary system can develop in ____of patients from the chronic inflammation.
15%
The most specific test for primary sclerosis cholangitis is an _____ This is the only chronic liver disease in which a liver biopsy is not the most accurate test.
ERCP or transhepatic
cholangiogram.
There is an overabsorption of iron in the duodenum, leading to iron buildup in a number of tissues throughout the body. This leads to chronic hepatic inflammation and fibrosis.
Hemochromatosis
Hemochromatosis
MC finding of hemochromatosis
Cirrhosis is the most common finding
Hemochromatosis
_____ occur with increased frequency because of their avidity for iron
Vibrio vulnificus and Yersinia infections
Hemochromatosis
screening
Screening for the disorder is by finding an elevated iron level and diminished
iron-binding capacity. The ferritin is also elevated.
Hemochromatosis
The most accurate test is ______
a liver biopsy and
abnormal C282Y gene;
Initial MX of Hemochromatosis
Phlebotomy is used to remove large amounts of iron from the bodyit removes
far more iron than do the chelating agents deferoxamine and deferasirox.
______ is an autosomal recessive disorder leading to the diminished
ability to excrete copper from the body. There is also increased copper absorption from the
small intestine
Wilson disease
_______develop because of copper deposition in the kidney
Fanconi syndrome and type II
proximal renal tubular acidosis
Dx of WD
The most specific blood test is a low ceruloplasmin level, but a low ceruloplasmin
level alone is not enough. There is also a high urinary copper level.
Tx of WD
The most specific blood test is a low ceruloplasmin level, but a low ceruloplasmin
level alone is not enough. There is also a high urinary copper level.
In WD,
Occasionally, there is a ______when the copper levels go high and are toxic to the red cells
hemolytic anemia
Function of the alpha-1 antitrypsin (AAT)
AAT protects the lungs so they can have normal function. AAT is made in the liver; without enough of it, the lungs become damaged, leading to emphysema
Genetic makeup of pts with AATD
Patients with AATD have 1 normal copy and 1 damaged copy, or they have 2 damaged
copies.
AATD MC Sx
The most prominent finding is emphysema developing at a young age in a nonsmoker
Dx of AATD
- ______, which examines a person’s genes and determines his genotype
- ______, which determines the type of AAT protein a person has
- _______, which determines the amount of AAT in a person’s blood
Alpha-1 genotyping
AAT PI type of phenotype test
AAT level test
