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GI Flashcards

1
Q

cholelithiasis (gallstones) types

A

cholesterol (green) - fat female fertile forty (native american, fmexican)

pigmented stones (black) - hemolysis

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2
Q

presentation of cholelithiasis

A

colicky RUQ abd pain radiates to the shoulder

worse with fatty foods - due to fats making the gallbladder contract more around sharp stones

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3
Q

dx and tx of choleliathiasis

A

dx - RUQ US

tx - cholecystectomy (elective) if pt not a surgical candidate then ursodeoxycholic acid

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4
Q

cholecystitis cause

A

obstruction in cystic duct + gall stone in gall bladder and gallstone is inflamed

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5
Q

cholecystitis presentation

A

constat RUQ pain
murphy signs +
inflammation –> mild fever and mild leukcytosis

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6
Q

dx of cholecystitis

A

dx - RUQ US - pericholecystic fluid, thickened gallbladder wall, glass stones present

  • if not conclusive –> HIDA scan –> monitors perfusion via tracer uptake which will show no uptake in the gallbladder due to an obstruction
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7
Q

tx of cholecystitis

A

NPO, IVF, IV ABX (cipro + metro or amp + genta + metro)
then
cholecystectomy (within 72-96hrs)

if not sx candidate - cholecystostomy - tube to drain the fluid

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8
Q

choledocolithiasis

A

gallstone somewhere in the common bile duct

liver keeps making bile –> it has nowhere to go so the bilirubin the bile leaks into the blood –> painful jaundice

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9
Q

choledocolithiasis presentation

A

if stone in ampulla vader –> liver inflammation (elevated AST and ALT) along with possible pancreatitis (elevated lipase and amylase)

+ painful jaundice
+/- murphy signs
elevated temp and WBC

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10
Q

dx of choledocolithiasis

A

RUQ US - showing dilated ducts due to an unseen obstruction

if inconclusive –> MRCP

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11
Q

tx of choledocolithaisis

A

NPO, IVF, IV ABX (genta + amp + metro or cipro + metro)
then
ERCP (urgently) –> cholecystectomy (electively)

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12
Q

cholangitis

A

dilated ducts due to stone obstruction as well as stagnant fluid which –> infection that can ascend the bile tract

infection is with the gut flora - so gram - rods anaerobics

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13
Q

presentation of cholangitis

A 
charcots triad 
RUQ pain 
painful jaundice 
fever
\+ 
hypotension and AMS = reynolds pentad
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14
Q

dx and tx of cholangitis

A

dx - RUQ US - obstruction effects

tx - IVF, IV ABX (genta + amp + metro or cipro + metro) –> emergent ERCP —> cholecystectomy (urgently)

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15
Q

overview of the causes of raquetball

A 
P-pill induce 
I-infectious 
E-eosinophilic 
C-caustic 
E- gErd/everything else

odonophagia - painful swallowing
dysphagia - difficulty swallowing

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16
Q

Pill induced esophagitis path

A

pills getting stuck typically temporarily –> inflammation and burning

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17
Q

common culprits in pill induced esophagitis

A

non enteric coated NSAIDs
abx - such as tetracycline
bisphonates
HAARTs

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18
Q

dx and tx of pill induced esophagitis

A

dx - endoscopy with biopsy

tx - if pill there remove it + remove offending agent + PPI
drink water with pill
avoid recumbency after taking pills

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19
Q

infectious esophagitis most common causes

A

Candidiasis
HSV
CMV
HIV

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20
Q

cadidiasis esophagitis

A

typically oral thrush seen as well

tx - fluconazole

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21
Q

HSV esophagitis

A

oral lesions
painful prodrome
vesicles on an erythematous base
multiple ulcers in different stages of healing

tx - Valacyclovir or acyclovir

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22
Q

CMV esophagitis

A

requires biopsy

tx - valacyclovir or agancyclovir

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23
Q

HIV esophagitis

A

opportunistic infections

HAART = tx

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24
Q

eosinophilic esophagitis

pathophys and causes

A

allergic rx to food –> eosinophils in the esophagus

asthma, allergies, atopy (eczema)

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25
Q

eosinophilic esophagitis dx and tx

A

endoscopy with biopsy showing > 15 eosinophils per high powered field

tx - PPI x 6wks - if fails –> oral aerosolized steroids

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26
Q

caustic esophagitis

A

kid who drinks draino
adult with suicide attempt drinks stuff

strong base or strong acid – > damage everything on the way down

larynx damage –> hoarse voice - if there is stridor intubate immediately as it is a sign of impending resp collapse

esophagus damage - drooling

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27
Q

dx of caustic esophagitis and tx

A

endoscopy with biopsy

mild severity - liquid diet 
high severity (aka strictures, necrotic black esophagus) ----> tx = NPO for 72hrs and repeat EGD
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28
Q

things you dont do with casutic esophagitis

A

dont neutralize the pH you will causes a thermophilic rx –> more burning

never induce emesis as it allows chemicals a second pass for destruction in the esophagus

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29
Q

if caustic esophagitis is caught very early on what can you do

A

insert NG tube and perform a lavage basically flush with water suction it up and do it over and over again

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30
Q

approach to dysphagia basics

A

motility (food and liquid issue) vs mechanical (progressive first food issues –> then liquid issues)

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31
Q

achalasia pathophys

A

absent myenteric plexus –> absence of inhibitory neurons –> LES cant relax –> always tight

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32
Q

achalasia presentation

motility disorder

A

food gets stuck at the mid sternum (GE junction) feels like a knot or a ball after they eat

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33
Q

dx of achalasia

A

barium swallow test –> shows birds beak

manometry –> shows abnormal high tone in LES

EGD with biopsy to r/o cancer

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34
Q

tx of achalasia

A

botilinum toxin - short acting - for non sx candidate
esophageal dilation - risk for perforation

myometry (best option) - ADR bad GERD

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35
Q

scleroderma pathophys

A

collagen deposition dz – > collagen replaces the smooth muscle of the LES –> no muscle no contraction of LES

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36
Q

scleroderma presentation

A

CREST - anticentromere
Systemic sclerosis - anti scl 70, anti topoisomerase

relentless GERD

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37
Q

dx and tx of scleroderma of the esophagus

A

barium - wide open
manometry - no contraction of LES
EGD with biopsy - lack of muscle
antibodies

tx - symptomatic PPIs

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38
Q

diffuse esophageal spasm

pathophys and presentation

A

random contractions of esophagus

MI like presentation retrosternal pain relieved by CCBs and NTG

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39
Q

dx and tx of diffuse esophageal spasm

A

r/o ACS –> barium (shows corkscrew appearance) –> manometry (shows random contractions)
EGD with biopsy

tx - CCBs and prn NTG

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40
Q

schatzki’s ring

A

ring at the GE junction

steakhouse dysphagia

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41
Q

dx and tx of schatzki’s ring

A

dx - barium –> narrowed lumen –> EGD with biopsy to r/o cancer –>

tx - during endoscopy lyse the ring

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42
Q

esophageal webs

A

plummer vinson syndrome

  • women with dysphagia
  • iron def anemia
  • webs
  • eventually esophageal cancer
  • koilonychia - spoon shaped finger nails
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43
Q

dx and tx of esophageal webs

A

dx - barium swallow

tx - Iron –> screen for cancer using EGD with biopsy

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44
Q

zenkers diverticulum presentation

A

halitosis - food sitting in the diverticulum
older man
regurgitation of undigested food

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45
Q

dx and tx of zenkers diverticulum

A

dx - barium study - diverticulum will fill –> EGD with biopsy

tx - surgical repair

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46
Q

stricture pathophys and presentation

A

Stage IV GERD –> progressive GERD that leads to stricture in bottom 1/3 of esophagus

progressive dysphagia and weight loss

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47
Q

dx and tx of an esophageal stricture

A

barium - circumfrential or symmetric loss of lumen –> EGD with biopsy

tx - high dose PPI with dilation of esophagus

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48
Q

Adenocarcinoma of the esophagus

A

long standing GERD –> irritation and change in bottom 1/3 of esophagus

GERD and weight loss dyshagia with solids first then liquids
more common in white men

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49
Q

dx and tx of adenocarcinoma of the esophagus

A

dx - barium - asymetric loss of the lumen –> EGD with biopsy

tx - chemo/radiation +/- surgery

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50
Q

squamous cell carcinoma of the esophagus

A

smoker and alcoholic + hot tea + hot food
african americans
upper 1/3 of esophagus affected

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51
Q

GERD pathophys

A

weakened LES –> acid continously regurgitating back into the esophagus

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52
Q

GERD presentation typical

A

burning chest pain

made worse by –> lying flat (recumbent position) and spicy foods

made better by –> sitting up and antacids

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53
Q

dx and tx of GERD

A

PPI + lifestyle modifications (avoid chocolate, peppermint, smoking, alcohol) for 6 weeks

if fails –> EGD + biopsy –> 24 hr pH monitor

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54
Q

alarm symptoms of GERD and workup

A

N/V
anemia (typically microcystic)
weight loss

EGD with biopsy

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55
Q

barrets esophagus

A

chronic GERD –> metaplasia to better handle acidity (leads to decreased pain)

tx - high dose PPI and recurrent EGDs for surveillance

however can lead to dysplasia (30-50 times increased risk for cancer (adenocarcinoma)

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56
Q

GERD and dysplasia seen on EGD with biopsy

A

tx - local ablation with either cryo, laser, radio frequency ablation and recurrent EGDs for surveillance

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57
Q

Nissen Fundoplication

A

person cant tolerate PPIs or doesnt want PPIs

mechanism = create a tighter LES if too tight leads to achalasia like symptoms

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58
Q

atypical symptoms of GERD

A

hoarseness
coughing
stridor
nocturnal asthma *

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59
Q

peptic ulcer disease basics

A

either gastric (gets worse with food) or duodenal (gets better with food then 2-5hrs later pain)

duodenal typically caused by H pylori

tx - stop smoking, stop drinking, stop NSAIDs

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60
Q

causes of peptic ulcer dz

A 
h pylori 
NSAIDs 
malignancy 
curling ulcers
cushing ulcers
zollinger ellison
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61
Q

NSAID PUD

A

multiple shallow ulcers - dx - with EGD with biopsy

tx - stop NSAID –> PPI BID then PPI daily

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62
Q

Malignancy PUD

A

EGD with biopsy –> big heaped up margins and necrotic centers - since cancer is outgrowing its blood supply

tx - stage and tx

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63
Q

Curling Ulcers
vs
Cushing ulcers

A

curling - burn pts

cushing - increased ICP —> tx - gut prophylaxis NGT and PPI

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64
Q

H Pylori - PUD

presentation

A

most pts asymptomatic, but some dyspepsia (indigestion) + epigastric pain

can present with a MALTOMA which will get better with tx of the h pylori

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65
Q

H pylori dx

A

serology - cant have a previous PUD dx - if + tx pt
urea breath test - need to be off PPI for test
stool antigen - after tx to see if eradicated
EGD with biopsy - best test - histology (best) can also do a rapid urease test

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66
Q

tx of h pylori

A

triple therapy
clarithromycin
amoxicillin (or metro if PCN allergy)
PPI

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67
Q

Zollinger Ellison syndrome

A

gastrinoma –> continously make gastrin –>which secretes HCl

big virulent refractory ulcers
pts keep failing PPI tx

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68
Q

dx of zollinger ellison syndrome

A

gastrin level > 1600 = diagnostic
gastrin levels 250-1600 –> secretin skin test –> gastrin levels go up = gastrinoma

somatostatin receptor syntography – looks for receptors of gastrinoma
CT scan

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69
Q

tx and complications of Zollinger Ellison syndrome

A

tx - resection

complication - malignancy

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70
Q

gastroperesis

A

gastric paralysis - fails to empty

MCC - idiopathic and another cause is diabetes —>(peripheral neuropathy of the vagus nerve)

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71
Q

presentation of gastroperesis

A

delayed gastric emptying
N/V, abdominal pain with eating

peripheral neuropathy (if diabetic)

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72
Q

dx of gastroperesis

A

endoscopy - r/o other dzs –> emptying study
> 60% after 2hrs = + result
> 10% after 4 hrs = + result

pts must be off opiates, anticholinergics, and have good blood glucose to do this study as these things delay emptying

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73
Q

tx of gastroperesis

A

avoid things that delay gastric emptying
low fiber and small volume diet

prokinetic agents

  • metachlopromide (PO) - good for chronic tx
  • erythromycin (IV) - good for flare up tx

donperidone - banned due to ADR - cardiac

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74
Q

cyclic vomiting syndrome

A

habitual chronic use of TSH
N/V cycles that can last wks

tx - stop TSH and metachlropromide or erythromycin and antiemetics (ondasterone)

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75
Q

gastric adenocarcinoma

A

increased incidence in east Asia
associated with nitrites

early satiety, weight loss, gastric outlet obstruction

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76
Q

dx and tx of gastric adenocarcinoma

A

dx - EGD with biopsy –> shows signet rings –> PET CT/ Pan CT

tx - resection and chemo

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77
Q

acute diarrhea timeline vs chronic diarrhea timeline

A

acute diarrhea <2wks

chronic diarrhea >4wks

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78
Q

signs of enterotoxic acute diarrhea

A

watery diarrhea only

most common cause = viral gastroenteritis –> tx = rehydration either PO > IV and loperimide

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79
Q

causes of enterotoxic acute diarrhea

A

C diff - recent abx
ETEC - travelers diarrhea, central America

Vibrio Cholera - contaminated water, fecal oral, 3rd world
S Aureus - proteinaceous food, eggs or potato salad

B Cereus - reheated rice, chinese buffet
Giardia - camping, fresh water

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80
Q

Invasive acute diarrhea signs and symptoms

A

bloody diarrhea
fever
leukocytosis
fecal wbcs –> lactoferrin test necessary to confirm

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81
Q

causes of invasive acute diarrhea

A

salmonella - raw eggs, raw chicken
shigella - HUS
EHEC - HUS, uncooked beef
Camplyobacter - MCC of invasive bloody diarrhea
A Histolyticum - Immunocompromised, HIV, AIDS

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82
Q

acute diarrhea signs that lead to a workup

A 
Fever >104
electrolyte imbalances 
recent abx use 
> 3 days 
bloody/pus 
severe abdominal pain 
immunocompromised 
hospitalized
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83
Q

workup steps for acute diarrhea

A

viral gastro –> no –> c diff –> no –> stool WBCs/RBCs –>
–> if + = invasive –> stool culture and colonoscopy –> if stool culture + and colonoscopy (-) = infection but if stool culture (-) and colonoscopy (+) medical dz

—> stool WBCs/RBCs = (-) –> enterotoxic –> parasites –> if (+) = parasitic infection if (-) = viral causes

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84
Q

c diff
path
presentation
dx

A

overgrowth of natural flora due to systemic abx killing normal flora off

watery diarrhea with smell

dx - c diff NAAT (nucleic acid amplification test)

tx - oral metro -> oral metro -> oral vancyo -> oral fidaxomycin –> fecal transplant

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85
Q

severe c diff

presentation and tx

A

fever, leukocytosis
megacolon
BUN/Creatine issues

tx - both oral vancomycin and IV metro

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86
Q

HUS

A 
bloody diarrhea after eating uncooked meat
renal failure (increased Cr decreased BUN)

microcytic anemia –> schistocytes on blood smear
decreased platelets

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87
Q

Dx and tx of HUS

A

dx - shigella like toxin assay

tx - supportive - if renal failure –> diaylize

best tx = plasma exchange

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88
Q

secretory diarrhea

A

nml osm gap
volumous

neg - fecal wbcs/rbcs/fat/ mucous
no change NPO
no night symptoms

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89
Q

osmotic diarrhea

A

increased osm gap
+ changes with NPO
+ fat

neg fecal wbcs/rbcs/ mucous
neg night symptoms

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90
Q

inflammatory diarrhea

A

+ fecal rbcs/wbcs/ mucous

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91
Q

stool osm gap

A

measure osm (290) - calculated [ x2 (Na + K)]

<50 = secretory 
>100 = osmotic
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92
Q

usual suspects for chronic diarrhea

A 
laxative abuse 
medications 
lactose intolerance 
c diff
celiac sprue
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93
Q

VIPoma

A

secretes VIP –> activates intestines
chronic diarrhea

dx - increased VIP levels

tx- resection

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94
Q

carcinoid

A

secretes serotonin –> GI symptoms only appear when metastasis to liver occurs

right sided heart fibrosis, valve problems, flushing, and diarrhea

dx - 5-HIAA in urine

tx - resection

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95
Q

Minerals absorbed in the duodenum

A

F - folate –> anemia
I - iron – > anemia
C - calcium –> osteoporosis

carbs –> bloating flatulence foul smelling belching

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96
Q

minerals absorbed in the terminal ileum

A

b12 –> anemia + peripheral neuropathy
bile salts –> loss of vit KADE

  • vit K loss –> bleeding
  • vit A loss –> night vision
  • vit D loss –> osteoporosis
  • vit E loss - -> nystagmus
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97
Q

pancreas’s role in absorption

A

protein breakdown –> problems here lead to low albumin like state

  • ascites
  • lower leg edema
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98
Q

malabsorption workup

A

100g Fat diet with stool collection for 72hrs

  • if < 14g/day = healthy
  • if > 14g/day –> malabsorption –> D -xylose absorption ——> absorbed = intestinal lumen is intact –> pancreas issue –> give pancreatic enzymes
  • –> not absorbed = intestinal lumen issue –> EGD with biopsy
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99
Q

celiac sprue

A

gluten allergy, autoimmune dz, IgA mediated

diarrhea, bloating, weight loss, iron def, osteoporosis
dermatitis herpitiformis –> celiac sprue

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100
Q

dx and tx of celiac sprue

A

dx - Abs - tissue transglutaminase (TTG)* or endomysial –> EGD with biopsy showing blunting of vili = loss of surface area for absorption

tx - avoid gluten (takes 3 to 4 months for affect)

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101
Q

lactose intolerance

A

older patients, asians, bloating, flatulence, foul smelling, diarrhea

brush border enzyme def

dx -avoid dairy

tx - avoid dairy or lactase enzymes

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102
Q

tropical sprue

A

causes by an infection
caribbean farmer, diarrhea, bloating, weight loss

dx - EGD with biopsy showing sprue

tx - abx

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103
Q

whipples disease

A

infection with T whippeli
malabsorptio, brain issues, joint issues, lymph issues

dx - EGD with biopsy –> (+) PAS macrophages or organisms on electron microscopy

tx - TMP-SMP or Doxycycline

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104
Q

presentation of a pt with diverticula

A

older pt > 50 y/o
constipation
diet - low fiber, no fruits, no veggies, increased red meat

dx - colonoscopy

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105
Q

diverticulosis

A

asymptomatic

tx - high fiber diet, increased fruits and veggies

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106
Q

diverticulosis uncomplicated

A

post prandial LLQ abd pain that is relieved by having a BM
> 50 years old

dx - clinical
tx- high fiber diet

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107
Q

diverticula hemorrhage

A

painless hematochezia
age > 50y/o

manage like GI bleed initially –> colonoscopy (after bleeding) or arteriogram (allows for embolization)

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108
Q

fecalith forming around diverticula

A

lead to perforation
bacteria set up shop

Left sided appendicitis –> constant LLQ abd pain –> fever, leukocytosis, tenderness LLQ

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109
Q

workup of fecalith and diverticula

A

KUB - if perf –> sx (ex lap) with IV abx
- if loops of small bowel and air fluid levels –> obstruction —-> sx

if nothing –> CT abd with contrast

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110
Q 
tx of fecalith diverticula 
- mild 
abscess
severe
refractory
A

mild - Abx cirpo + metro or genta + ampicillin + metro (PO) liquids

abscess - NPO, IV abx, drain

severe - NPO, IV abx

refractory - hemicolectomy after treating initial diverticulitis episode

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111
Q

risks for colon cancer

A

age > 50
alcohol, smoking
obesity, processed red meats

inflammatory disorders (UC, crohns, primary sclerosing cholangitis)

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112
Q

presentations of colon cancer

A

1 - asymptomatic - found on screen
2- iron def anemia in older men and post menopausal women
3 - lumen obstruction - change in caliber of stools, constipation - diarrhea - constipation - thin

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113
Q

good polys vs bad polyps

A

good polyps - pedunculated, tubular, small

bad polyps - sessile, villous, large

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114
Q

tx of colorectal surgery

A

resection
stage and chemo
Fol Fox/ Fol Firi (VEGF - inhibitor) - bevacuzimab

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115
Q

turcots

A

brain tumors

colorectal cancer

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116
Q

gardners

A

jaw tumors

colorectal cancer

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117
Q

screen for colon cancer

A

colonoscopy - 50 y/o - every 10 yrs - up 75yrs old
flexible sigmoidoscopy - age 50 - every 5 years with fecal occult blood testing every 3 years

fecal occult blood testing every year

barium enema - apple core signs

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118
Q

colonoscopy severity levels

A

no risk - repeat 10 yrs
low risk - 1-2 polyps, <1cm, tubular, low grade dysplasia - repeat colonoscopy 5-10yrs

high risk - >3 polyps, >1cm, villious, high grade dysplasia - repeat colonoscopy 1-3 yrs

Mega risk - >10polyps, piece meal, sessile polyp - repeat colonoscopy in 2-6 months

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119
Q

FAP

A

APC gene defect
thousands of polyps

  • prophylactic colectomy by age 18yrs
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120
Q

lynch syndrome (HNPCC)

A

defect in DNA mismatch repair
C-colorectal cancer
E - endometrial cancer
O - ovarian cancer

3 members of family in 2 generations and 1 early diagnosed cancer

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121
Q

peutz jegher syndrome

A

freckles around mouth and on lips
no colon cancer
cancer of small intestine

dx - endoscopy

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122
Q

Causes of Cirrhosis

A 
V -viral hep b,c
W- wilsons
H-hematochromatosis 
A-alpha 1 antitrypsin def
P-primary sclerosing cholangitis 
P - primary biliary cirrhosis 
E- etoh
N-NASH/Non alcoholic fatty liver dz
S-something else
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123
Q

Viral Hepatitis B and C

A

chronic inflammation
Hep C - IV drugs
Hep B - sex workers

dx - abs
tx - direct acting antagonists

124
Q

Wilsons dz

A

copper deposition - basal ganglia - chorea - liver cirrhosis - eyes keyser fleischer rings

dx - slit laamp, serum ceruplasmin, urinary copper, biopsy = best

tx - penicllamine –> Transplant

125
Q

hemachromatosis

A

iron overload, bronze diabetes, iron in skin and iron in pancreas, HFE mutation

cirrhosis, diastolic CHF,

126
Q

dx and tx of hemachromatosis

A

dx - ferritin level >1000 or transferrin > 50%, biopsy with increase iron

tx - deforaxamine, blood letting

127
Q

alpha 1 antitrypsin def

A

accumulates in liver, young COPD pt with cirrhosis

dx - biopsy with PAS + macrophages

tx - transplant

128
Q

primary sclerosing cholangitis

PSC - s for sons of bitches

A

extrahepatic dz
pruritus, painless jaundice
30-50 y/o Men

associated with UC, IBD

129
Q

dx and tx of primary sclerosing cholangitis

A

dx - ANCA, MRCP - beads on string - biopsy showing onion skinning and fibrosis

tx - ursodeoxycholic acid –> transplant

130
Q

primary biliary cirrhosis

PBS - b for bitches

A

intrahepatic dz
pruritis, painless jaundice
30-50 y/o Females

dx - nml imaging - AMA - biopsy best

tx - transplant

131
Q

Liver functions

A

make bile and bile salts - jaundice + pruritus
make albumin - low albumin
make clotting factors 2, 7, 9, 10 - bleed
process toxins (NH3) - hepatic encephalopathy
makes estrogen - gynecomastia, spider angiomatas, palmar erythema

132
Q

hepatic encephalopathy

A

NH4+ goes to brain
confused AMS, asterexis (Flapping tremor)

dx lcinical

tx- lactulose + rifaximin + Zinc

133
Q

Portal HTN

A

thrombocytopenic, splenic sequestration
ascites
portal caval shunts - varices, hemorrhoids, caput medusa

134
Q

Varices presentation

A

in esophagus

  • either dx by accident with endoscopy or
  • dx by bleeding fast and hard from both ends
135
Q

management of bleeding varice

A

bleeding - bound them for short term, balloon, banding

reduce portal pressure with beta blockers such as nadolol and propranolol

+ ceftriaxone + octreotide (reduces portal pressure acutely)

last resort TIPS procedure until transplant - plastic tube that bypasses the liver shunt from portal vein to vena cava - can lead to worsening of hepatic encephalopathy

136
Q

Ascites

A

fluid in the belly
portal HTN = SAAG >1.0 - cirrhosis, RHF
non portal HTN = <1.1 - infection TB, cancer

dx - paracentesis

137
Q

presentation of ascites and tx

A

bulging, flanks, shifting dullness, fluid wave

tx - furosemide + spiranolactone and therapeutic paracentesis

138
Q

Spontaneous bacterial peritonitis

A

strep and gram neg rods
asymptomatic and occasionally fever and abd pain

dx - paracentesis - PMNs > 250

tx - IV ceftriaxone, if protein < 1 - prophylaxis fluoroquinolone

139
Q

secondary bacterial peritonitis

A

culture comes back + with many diff types of organisms = perforated bowel –> tx ex lap

140
Q

hepatocellular carcinoma

A

path - chronic inflammation - cirrhosis or hep B
asymptomatic

risk - black, asian, aflatoxin, vinyl chloride, AAT def

screen = RUQ US + AFP - confirmatory test = triple phase CT - cancer lights up in arterial phase

141
Q

tx of hepatocellular carcinoma

A

small - resect
medium - transplant
big - radiofrequency ablation or chemo/embolization

142
Q

what separates a lower GI bleed from an upper GI Bleed

A

ligament of treit

upper Gi bleed - hematemesis, melena, hemaochezia (unstable)

lower Gi bleed - hematochezia (stable)

143
Q

most common causes of an upper GI bleed

A

PUD - in non cirrhotic
Varices - in cirrhotic
GERD
Dieulafuys lesion

AVM

144
Q

most common causes of a lower GI bleed

A

Diverticular hemorrhage
hemorrhoids
cancer
AVM

145
Q

stabilizing an acute GI bleed

A

2 large bore IVs 18gauge or higher
IVF
IV PPI
Type and cross –> transfuse

if cirrhotic - octreotide and ceftriaxone

146
Q

lower Gi bleed workup - rate of bleeding

A

brisk - arteriogram - dx and embolize if needed

ongoing not brisk - tagged RBC scan

no bleeding - colonoscopy

nothing found after all this - pill camera endoscopy

147
Q

mallory weiss tear

A

superficial esophageal mucosa tear
weekend warrior that parties too much

dx - EGD

tx - supportive, self limiting

148
Q

boorheaves syndrome

A

transmural tear in the esophagus
career vomiter - alcoholic, bulimics

sick appearing, fever, dyspneic,
on CXR or physical exam - air in the mediastinum (rice crispy crackles)

149
Q

dx and tx of boorheaves syndrome

A

dx - 1st gastrografffin if nml –> barium if nml –> EGD

  • if any point = perf –> surgery = tx
150
Q

Dieulafoys lesion

A

anatomical variant - artery close to the mucosal surface t
erosions eventually get into it and cause bleeding

brisk painful bleed

dx - EGD
tx - resect

151
Q

hemorrhoids

A

internal - bleed, painless
external - painful, itchy, no bleeding

blood on toilet paper or on stool but not mixed in

dx - clinical

152
Q

tx of hemorrhoids

A

sitz bath
prep H
hemorrhoidectomy

153
Q

diverticular hemorrhage

A

> 50 yr painless bright red blood per rectum

arteriole in the dome of the diverticula = cause

dx - colonoscopy
tx - hemicolectomy

154
Q

mesenteric ischemia

A

CAD of the gut “gut attack”
vasculopath - afib, CAD, recent arteriography

pain out of proportion to physical exam
abd pain with eating -> avoid eating -> weight loss

155
Q

dx and tx of mesenteric ischemia

A

dx - arteriogram

tx - resect or revascularize

156
Q

ischemic colitis

A

watershed arteries
hypotensive pts
painful bright red blood per rectum

157
Q

dx and tx of ischemic colitis

A

dx - colonoscopy

tx .- supportive

158
Q

AVM has an association with

A

Aortic stenosis

159
Q

causes of pancreatitis

A

MCCs in US = alcohol and gallstone

other causes - meds, hypertriglycedemia, trauma (due to ERCP)

160
Q

presentation of pancreatitis

A

epigastric abdominal pain that radiates to back
positional pain - worse leaning back, better leaning forward

N/V and anorexia (return of appetite - good sign)

cullens sign - periumbilical hematoma
turners sign - flank hematoma

161
Q

dx of pancreatitis

A

Lipase - 3x upper limit of nml
amylase - amylase p

if enzymes dont support dx get CT if sure
US will show gallstones if they are the cause
MRCP will show cause if they are strictures/malignancy

162
Q

tx of pancreatitis

A

NPO, IVF, pain meds –> refeed them on demand

if abx need to be used -> meropenim > cipro

if gallstone = cause - ERCP if stone fails to pass on its own

163
Q

early complications of pancreatitis 1-3 days

A

ARDS - noncardiogenic pulm edema - dx - CXR - tx - intubate

Saponification - low Ca turns pancreas into soap - dx - ion Ca [ ] -> tx - give Ca

Fluid shift - ascities (dx - US) and/or pleural effusion (dx - CXR) dont drain either unless its infectious

164
Q

mid complication of pancreatitis (1-3wks)

A

Infection - necrosis on CT –> biopsy for dx

tx - meropenem until cultures show specific sensitivity

165
Q

late complications of pancreatitis (3-7wks)

A

abscess - fevers, swelling, induration, redness - dx - CT - tx - drain and abx

pseudocyst - CT for dx - pocket of fluid - Small bowel obstruction, early satiety, abd fullness

  • –> tx = < 6wks + < 6cm = watch and wait
  • —> tx = > 6cm or > 6wks = drain and biopsy
166
Q

best test to assess prognosis in pancreatitis

A

BUN (most sensitive)

167
Q

Ulcerative Colitis basics
age range
endoscopy
biopsy

A

20-30yrs old

endoscopy - continuous lesions from rectum through colon

Biopsy - superficial crypt abscess

168
Q

UC
risk of malignancy
extra intestinal manifestations
role of surgery

A

increased risk of colon cancer
colonoscopy at year 8 and every year after

primary sclerosing cholangitis
P- ANCA

surgery = curative (colectomy)

169
Q

Crohns disease basics
age
endoscopy
biopsy

A

age - 20s and 50-70s

endoscopy - skip lesions throughout entire GI tract, cobblestoning

biopsy - transmural noncasseating granulomas

170
Q

UC - presentation

A

bloody diarrhea

171
Q

Crohns disease presentation

A

watery diarrhea,
multiple bowel movements per day
nutritional def
weight loss

172
Q

Crohns
risk of malignancy
extra intestinal manifestations
role of sx

A

no risk of malignancy

fistulas
terminal ileum - B12, fats def
duodenum - iron def, osteopenia

sx only for complications - fistulas and abscesses

173
Q

tx of mild IBD

A

for UC - 5-ASA compounds - such as mesalmine - anti inflammatory

174
Q

tx of moderate IBD

A

Immunomodulators for both UC and crohns

- 6 mercaptopurine, Azothiprine, and MTX

175
Q

tx of severe IBD

A

UC - surgery

Crohns - TNF inhibitors - Infliximab

176
Q

tx of flares for IBD

A

steroids (IV vs po) dependent on severity
+
Abx (cipro + metro) or (ampicillin + genta + metro)
—–> covers gram - and anaerobes

perianal dz needs to be drained

177
Q

rate limiting step of bilirubin conjugation

A

2,3 UDP gluconuryl transferase

- makes unconjugated –> conjugated

178
Q

prehepatic jaundice causes

A

hemolysis
reabsorption of a hematoma

increased unconjugated bilirubin

179
Q

posthepatic jaundice causes

A

obstruction

  • painful = gallstones
  • painless = cancer, stricture, PSC, PBC

increased conjugated bilirubin

180
Q

intrahepatic jaundice

A

criggler naiger + gilberts = increased unconjugated
dubin and rotors = increased conjugated
—-> roto - black on MRI

hepatitis and cirrhosis = mixed picture

181
Q

conjugated bilirubin basics

A

water soluble – cant cross BBB

excreted in urine –> dark urine

182
Q

unconjugated bilirubin basics

A

fat soluble —> can cross BBB –> kernicterus (peds)

not excreted in urine

183
Q

Hep A basics
transmission
serology
etc

A

fecal oral - contaminated water, no hand washing
acute infection, no cancer risk

RNA virus with Vaccine
IgM = infected
IgG = Immune

184
Q

Hep B basics
transmission
etc no serology

A

SEX, blood transfusion or IV drug users
chronicity = cancer risk with cirrhosis is possible

DNA virus with Vaccine

185
Q

Hep C basics
transmission
etc no serology

A

Blood transfusion and IV drug users
chronicity = cancer risk
RNA virus

No vaccine

186
Q

Hep D

Hep E

A

Hep D - RNA virus must have Hep B present or chronic to get infected with Hep D

Hep E - 3rd world pregnant women

No vaccines for either

187
Q

Hep C serology
+Ab and +HCV RNA =
- Ab and + HCV RNA =
+ Ab and - HCV RNA =

A

+Ab and + HCV RNA = infected

(-) Ab and + HCV RNA = acute infection

+Ab and (-) HCV RNA = treated

188
Q

treatment of Hep C

A

protease inhibitors (direct acting antagonists) such as ——–> Borcepravir

old school = ribavirin and interferon

189
Q

Hep B serology

HBs Ag =

A

infected

190
Q

HBeAg

A

infectious

191
Q

IgM HBsAg

A

early infection

192
Q

IgG HBsAg

A

immune (either exposed or vaccinated)

193
Q

IgG HBcAg

A

immune due to exposure

194
Q

toxic megacolon

presentation

A

increased risk if hx of IBD

sepsis + bloody diarrhea
- fever, leukocytosis tachy, AMS, anemia, hypotension

195
Q

toxic megacolon dx

A

plain abd X-rays = dilated right or transverse colon > 6cm
multiple air fluid levels
thick haustral markings that dont cross entire lumen

196
Q

toxic megacolon tx

A

medical emergency - since it can lead to perf

IVF, broad spectrum abx, bowel rest, NGT decompression

if IBD Hx –> IV corticosteroids

197
Q

toxic megacolon in HIV pts caused by

A

CMV

198
Q

right colon cancer vs left colon cancer

A

right colon - anemia

left colon - obstruction

199
Q

Non alcoholic fatty liver dz associated with

A

insulin resistance and if BMI > 35 consider bariatric surgery

200
Q

what can exacerbate hepatic encephalopathy

A

hypokalemia –> lead to increased NH3

201
Q

Neomycin

A

nonabsorbable abx that is used to tx hepatic encephalopathy in pts unrepsonsive to lactulose and those who cant tolerate rifaximin

202
Q

Chronic pancreatitis causes

A

alcohol
CF
ductal obstruction
autoimmune

203
Q

chronic pancreatitis presentation

A

chronic epigastric pain that is intermittent with pain free episodes

malabsorption - steatorrhea, and weight loss
DM

204
Q

chronic pancreatitis dx

A

CT scan or MRCP showing calcifications and an enlarged pancreas

205
Q

complications of primary biliary cholangitis

A

malabsorption fat soluble vitamin def
metabolic bone dz - osteoparosis, osteomalacia

hepatocellular carcinoma

206
Q

alcoholic hepatitis dx

A

AST/ALT about 300s
increased gamma glutamyl transferase
increased ferritin

207
Q

signs of acute liver failure

A

hepatic encephalopathy
AST, ALT > 1000s
INR > 1.5

208
Q

drugs that cause drug induced pancreatitis

A

furosemide
thiazides
tetracyclines
metronidazole

209
Q

NSAIDS are a common cause of

A

iron def anemia

210
Q

pancreatic tumor presentation

A

weight loss
painless jaundice
nontender distended gallbladder

211
Q

imaging findings of pancreatic cancer

A

intra and extrahepatic biliary tract dilation

increased alk phosp

212
Q

alcoholic hepatitis presentation

A

jaundice
anorexia
fever
RUQ pain

abdominal distension
proximal muscle weakness

213
Q

when is a transfusion is recommended for a GI bleed and esophageal varices

A

GI bleed <7

Esophageal < 9

214
Q

when is a platelet transfusion indicated

A

<72,000

215
Q

biggest environmental risk factor for pancreatic cancer =

A

smoking

followed by obesity and chronic pancreatitis

216
Q

laxative abuse

A

frequent watery nocturnal diarrhea

colonoscopy –> + if melanosis coli is seen –> dark brown discoloration with pale patches of lymph follicles

217
Q

SAAG formula

A

serum albumin - peritoneal fluid albumin

SAAG >1.0 = increased hydrostatic pressure in capillaries

218
Q

wilsons disease

A

5-35years old
hepatic - ALF, chronic hepatitis, cirrhosis,
neuro - parkinsonism, gait disturbance, dysarythria
psych - depression, personality changes, psychosis

219
Q

dx test of choice in almost all esophageal swallowing diseases

A

barium swallow test

220
Q

angiodysplasia

A

dilated submucosal veins and arteriovenous malformations

common cause of recurrent painless GI bleeding

dx colonoscopy
tx - asymptomatic

221
Q

large linear ulcers in the esophagus =

A

CMV

222
Q

potassium chloride = risk factor for

A

pill induced esophagitis

223
Q

acute erosive gastropathy

A

development of hemorrhagic lesions after ischemia or the exposure of gastric mucosa to various injurious agents (aspirin, cocaine, alcohol)

224
Q

total parental nutrition risk factors

A

gallbladder stasis and predisposes to gallstone formation and bile sludging –> both can lead to cholecystitis

225
Q

pseudoachalasia

A

narrowing of distal esophagus secondary to causes other than denervation (esophageal cancer)

endoscopy required for dx

226
Q

spontaneous bacterial peritonitis

A

pt with cirrhosis and ascites
low grade fever, abd discomfort, AMS

dx - PMNs > 250, + cultures, SAAG >1.0, protein <1

tx - ceftriaxone or fluoroquinolones for prophylaxis

227
Q

alarm symptoms of GERD that suggest performing and endoscopy

A 
melena 
persistent vomiting 
hematemesis 
weight loss 
anemia
dysphagia/odonyphagia
228
Q

the hallmark of ischemic hepatopahty

A

rapid rise and significant increase in the transaminases

increased bili and alkaline phosphatase

229
Q

when is an ERCP performed

A

when CT or US have shown the presence of an obstruction that is due to cholelithiasis or malignancy

ERCP here = diagnostic and therapeutic

230
Q

elevated alk phos

and elevated GGT

A

think cholestasis
or
malignancy if pt presentation is consistent

231
Q

INH side effects

A

idiosyncratic liver injury

Histo resembles viral hepatitis - panlobular mononuclear infiltration and hepatic cell necrosis

232
Q

elevated BUN and BUN:Cr

A

upper GI bleed

233
Q

DOC of primary biliary cholangitis

A

ursodeoxycholic acid

- increases hydrophobic endogenous bile acids which decreases biliary injury

234
Q

CT findings of mesenteric ischemia

A

bowel wall thickening
pneumatosis intestinalis
mesenteric thrombi

235
Q

polyps that carry increased risk for malignancy

A

adenomatous polpys

  • large >1cm
  • high grade dysplasia

villous features = greatest risk of malignancy

236
Q

Niacin def

A

can be caused by prolonged INH therapy

3 D’s - diarrhea, dementia, dermatitis (Pellagra)

237
Q

esophageal stricture

A

product of GERD and barretts esophagitis

symmetric and circumferential narrowing of the lumen of the esophagus —> dysphagia of solids

238
Q

D-xylose cannot be absorbed -

A

proximal small intestine mucosal dz (Celiacs)

there will be lose D-xylose in urinary and venous systems

239
Q

Normal D-xylose absorption

A

overall malabsorption in this pt is due to enzyme deficiencies

240
Q

hepatic adenoma

A

well demarcated, hyperechoic lesions
young woman with OCP hx
anabolic steroid user

241
Q

C diff risk factors

A

recent abx use
hospitalization
PPI use - gastric acid suppression

242
Q

copper def

A

brittle hair

skin depigmentation
neuro - ataxia, peripheral neuropathy

sideroblastic anemia
osteoporosis

243
Q

chromium def

A

impaired glucose control in diabetics .

244
Q

selenium def

A

thyroid dysfunction
cardiomyopathy
immune dysfunction

245
Q

Zinc def

A

alopecia - pustular skin rash (perioral and extremeties)

impaired wound healing
impaired taste

hypogonadism
immune dysfunction

246
Q

hepatic hydrothorax

A

results in transudative pleural effusions

thought to occur due to small defects in the diaphragm

247
Q

tense ascites can lead to

A

decreased range of diaphragmatic excursion –> increased intraabdominal pressure

248
Q

MCC of large bowel obstruction in adults

A

colorectal carcinoma

249
Q

rectal cancer presentation

A

hematochezia - MC symptom
tenesmus
rectal mass - incomplete evacuation

250
Q

complications of diverticulitis

A

bowel obstruction
abscess
fistula
clonic perf - rare

251
Q

test of choice for diverticulosis

A

barium enema

CT = test of choice for diverticulitis with oral and iv contrast

252
Q

what tests are contraindicated in acute diverticulitis

A

barium enema and colonoscopy as they can cause a perforation

253
Q

acute mesenteric ischemia path

A

compromised blood supply - typically the superior mesenteric vessels

avoid vasopressors as they worsen ischemia

254
Q

4 types of acute mesenteric ischemia causes

A

embolic - cardiac origin - sudden and painful

arterial thrombis - CAD hx, PVD hx- more gradual less severe

nonocclusive mesenteric ischemia - splanchnic vasoconstriction - ill old pts

venous thrombus - predisposing virchow triad - gradually worsening over course of weeks

255
Q

signs of intestinal infarction

A

hypotension, tachypnea
lactic acidosis
fever, AMS

256
Q

dx test for mesenteric ischemia

A

mesenteric angiography and check the lactate levels

257
Q

colon distension past >10cm

A

impending rupture –> peritonitis and death - decompress immediately

258
Q

most freq implicated abx for c diff

A

clindamycin
ampicllin
cephalosporin

259
Q

complications of c diff

A

toxic megacolon
colonic perforation
anasarca
electryolyte imbalances

260
Q

colonic volvulus

A

twisting of loop of intestine about mesenteric attachment site –> vascular compromise

most commonly = sigmoid colon

261
Q

dx of colonic volvulus and tx

A

dx - plain abd films - omega loop sign

tx - sigmoidoscopy can be therapeutic

262
Q

octeotride MOA for varices tx

A

causes splanchnic vasoconstriction and reduces portal pressure

263
Q

gold standard for cirrhosis dx

A

biopsy

264
Q

precipitants to hepatic encephalopathy

A

alkalosis - hypokalemia due to diuretics
sedating drugs (narcotics, sleep medications)
GI bleeding, systemic infection

265
Q

MOA of lactulose

A

prevents absorption of ammonia by favoring formation of NH4 which is excreted

266
Q

rifaxmin MOA for Hepatic encephalopathy

A

kills bowel flora so decreased ammonia production by intestinal bacteria

267
Q

tx of coagulopathy in cirrhosis

A

fresh frozen plasma

268
Q

tx of wilson dz

A

chelators - penicallimine and zinc - prevents uptake of di

269
Q

most common malignant liver tumor

most common bengin liver tumor

A

malignant = HCC and cholangiocarcinoma

benign - hemangioma

tumor marker = AFP

270
Q

hemobilia

A

caused by trauma

blood draining into duodenum via the CBD

dx - arteriogram

Tx - resect

271
Q

hydatid liver cyts

A

echinoccocus granulossis - MC right lobe

larger cysts may rupture –> anaphylactic shock

tx - resect without spilling contents

272
Q

amebic liver disease

A

MC in men 9:1 gay men, fecal oral route

reach the liver via the hepatic portal vein
RUQ pain, N/V, diarrhea (bloody)

tx- IV metro

273
Q

Budd Chiari Syndrome

A

liver disease caused by occlusion of hepatic venous outflow which leads to hepatic congestion and subsequent microvesicular ischemia

  • cause - hypercoagulable state and idiopathic
274
Q

causes of conjugated hyperbilirubenemia

A

decreased intrahepatic excretion of bili

extraheaptic biliary obstruction

275
Q

causes of unconjugated hyperbilirubenemia

A

excess production of bili
reduced hepatic uptake of bilirubin
impaired conjugation

276
Q

gilbert syndrome can be exacerbated by

A

fasting - fad diet
fever
alcohol
infection

277
Q

ALT, AST
100s
800s
1000s

A

100s - chronic hepatitis or acute alcoholic hepatitis
800s - acute viral hepatitis

1000s - extensive hepatic necrosis

  • ischemia
  • acetaminophen toxicity
  • severe viral hepatitis
278
Q

murpheys sign

A

pathognomonic for acute cholecystitis

inspriatory arrest during deep palpation of the RUQ

279
Q

HIDA scan

A

used when US inconclusive - if gallbladder not visualized after 4hrs post injection - dx of acute cholecystis is confirmed

280
Q

signs of biliary tract obstruction

A

increased alk phos
increased GGT
increased conjugated bilirubin - juandice, pruritus pale colored stools, dark urine

281
Q

complications of cholecystitis

A

gangrenous cholecystitis
perf of gallbladder
emphysematous cholecystitis

cholecysteoenteric fistula with gall stone ileus
empyema of gall bladder

282
Q

tx of choledocolithiasis

A

ERCP with stone removal and sphinctomoty

283
Q

most serious complication of cholangitis

A

hepatic abscess - high mortality rate

284
Q

dx appearance of PSC on ERCP

A

beadlike dilitations

285
Q

CCK hormone

A

relaxes sphincter of oddi

contracts the gallbladder

286
Q

biliary dyskinesia

A

motor dysfunction of sphincter of oddi –> recurrent episodes of biliary colic without evidence of gallstones

287
Q

dx of biliary dyskinesia

A

HIDA scan - once gallbladder is filled with radionucleotide –> inject CCK –> if EF of gallbladder is low = dyskinesia

288
Q

risk factors for appendix perf

A

> 24hrs

extremes of ages (toddler or elderly)

289
Q

signs and symptoms of appendix rupture

A

high fever, tachypnea, marked leukocytosis
peritoneal signs - rigid abdomen, guarding, rebound tenderness

sick as shit

290
Q

peritoneal signs

A

rigid abdomen, guarding rebound tenderness

291
Q

acute appendicitis path

A

lumen obstructed by hyperplasia of lymphoid tissue –> fecalith or FB –> stasis –> bacteria grows –> inflammatio –> distension –> compromise of blood supply –> ischemia –> necrosis –> perf or peritonitis

292
Q

presentation of appendicits

A

epigastrium abd pain –> umbilicus pain –> RLQ

sharp pain due to irritation to parietal peritoneum
anorexia, N/V

293
Q

Where do carcinoid tumors originate from

A

neuroendocrine cells and secrete serotonin

ileal carcinoid tumors have the greatest risk of malignancy

294
Q

MCC of pancreatitis in kids

A

blunt abd trauma

295
Q

pancreatic pseudocyst

A

lack epithelial lining - encapsulated fluid collection that appears 2-3 wks after pancreatitis

dx - C scan and tx - if >5cm drain it

296
Q

aortoenteric fistula

A

pt has hx of aortic graft surgery
presents with small GI bleed and then has a massive GI bleed hrs to weeks later - perform endoscopy early to prevent second bleed

297
Q

dark stools can also be caused by

A 
bismuth
iron 
spinach 
charcoal 
licorice
298
Q

ingesting alkali or acids is worse

A

alkali - may lead to liquefactive necrosis of esophagus with full thickness perf

299
Q

most important determining factor for survival in an esophageal perf

A

time from perf to surgery

300
Q

Misoprostol

A

reduces risk for ulcer formation associated with NSAID therapy

301
Q

krunkenberg tumor

A

gastric carcinoma that mets to ovary

302
Q

causes of small bowel obstruction

A

adhesions from previous sx = MCC

incarcerated hernia

303
Q

presentation of SBO

A

cramping abdominal pain - if continuous can be a sign of strangulation

obstipation

304
Q

dx of SBO

A

plain abd films - dilated loops of small bowel air fluid levels proximal

305
Q

MCC of a large bowel obstruction

A

colon cancer

306
Q

presentation of bowel strangulation

A

fever, severe and continuous pain
hematemesis
shock

gas in bowel wall or portal vein
abdominal free air
acidosis - increased lasctic acid

307
Q

other complications of crohns disease

A

kidney stones

gallstones

Step 2 Rotation Cards (14 decks)

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