GI Flashcards
PANRE
Which of the following tumor markers is useful in monitoring a patient for recurrence of colorectal cancer after surgical resection?
Carcinoembryonic antigen-an be used to monitor a patient for the return of colorectal cancer after treatment.
A patient develops abdominal cramps and watery diarrhea 10 to 12 hours after eating a plate of unrefrigerated meat and vegetables. The patient denies vomiting. The causative agent is most likely
Food poisoning caused by Clostridium perfringens has an incubation period of 6 to 24 hours and results from poorly refrigerated cooked meat.
The most common initial presenting symptom of primary biliary cirrhosis is
Pruritus is the most common initial symptom in primary biliary cirrhosis due to the accumulation of bile salts.
Which of the following is the therapy of choice for long-term management of esophageal varices in a patient who cannot tolerate beta blocker therapy?
Sclerotherapy is effective in decreasing the risk for rebleeding in a patient with esophageal varices.
Initial pharmacologic treatment of acute hepatic encephalopathy consists of
Lactulose acts as an osmotic laxative decreasing ammonia absorption and decreases ammonia production by directly affecting bacterial metabolism.
A 72 year-old male presents to the ED complaining of acute onset of severe diffuse abdominal pain of four hours duration. He states that he has vomited twice since the onset of pain. He also complains of three days of constipation. He is afebrile and the physical examination is noteworthy for a distended, diffusely tender abdomen with normoactive bowel sounds. His rectal exam reveals hemoccult positive brown stool.Medications include omeprazole (Prilosec) for GERD, digoxin and warfarin (Coumadin) for atrial fibrillation,OTC multivitamins and stool softeners. The abdominal and chest x-rays show no abnormalities. Which of the following is the most likely diagnosis?
Mesenteric infarction
Which medication is considered the mainstay of therapy for mild to moderate inflammatory bowel disease?
Question 12 Explanation: Sulfasalazine and other 5-aminosalicylic acid drugs are the cornerstone of therapy in mild to moderate inflammatory bowel disease as they have both anti-inflammatory and antibacterial properties.
Congenital absence of ganglionic nerve cells innervating the bowel wall is seen in which of the following conditions?
Hirschsprung disease, also termed congenital aganglionic megacolon, results from a lack of ganglion cells in the bowel wall.
A middle-aged patient is being treated for recurrent diarrhea and peptic ulcer disease that is refractory adequate standard therapy. Which of the following is the most likely diagnosis?
Zollinger-Ellison syndrome is the result of unregulated release of gastrin resulting in gastric acid hypersecretion. Up to 50% of patients complain of diarrhea along with peptic ulcer disease.
Which of the following is suggestive of thiamine deficiency?
Ataxia, mental deficits, horizontal nystagmus, muscle weakness and atrophy, and cardiomegaly are all clinical findings in thiamine deficiency
Which of the following would be consistent for a person who has a successful response to the hepatitis B immunization series?
HBsAg negative; anti-HBc negative; anti-HBs positive
Which of the following presents the greatest risk factor for the development of pancreatic cance
igarette smoking is the most consistent risk factor for the development of pancreatic cancer.
The parents of a 16 year-old male presents to the clinic with their son asking that you examine him. Over the past 9-12 months he has developed behavioral problems and emotional lability. Physical examination reveals a well-developed male who is cooperative with exam but tends to be easily distracted. It is noteworthy for dysarthria, a resting tremor and the presence of gray-green pigmentation surrounding each pupil. The most likely diagnosis is
Wilson’s disease results in the excessive deposition of copper in the liver and brain. Kayser-Fleisher rings are the result of granular deposits in the eye and are pathognomonic for Wilson’s disease.
Causes of Acute hepatitis (Level 1)
Most common causes are viruses and drugs (acetaminophen, alcohol, INH)
S/S of Acute hepatitis (Level 1)
S/S:
○ Prodromal phase: Malaise, fatigue, anorexia, N/V, abd pain, joint pain, HA
○ Icteric phase: Jaundice
DX of Acute hepatitis (Level 1)
↑ ALT > ↑ AST, both > 500, ±↑ bilirubin
○ Alcoholic hepatitis AST/ALT >2
Hepatitis A -s/s (buzz word)
Associated with spiking fever
DX of Hep A
Acute: + IgM HAV Ab
○ Past exposure: + IgG HAV Ab with neg IgM
Prevention of HEP A
Hep A vaccine for high risk population
+ HBsAg
1st evidence of infection before symptoms
■ If stays positive > 6mo → chronic infection
+ HBsAb
Indicates immunity
+ HBcAb
IgM = acute infection, 1st Ab to appear
■ IgG = prior or current infection
+ HBeAg
Indicates ↑ viral replication and infectivity
■ Important indicator of transmissibility (“BE”ware!)
+ HBeAb
Waning viral replication and infectivity
■ Low transmissibility
Prevention of Hep B
Hep B vaccine x 3 doses as infant, contraindicated if allergic to Baker’s
yeast
CI of Hep B
allergic Baker Yeast
Hepatitis C transmission
Parenteral (IV drug users, blood transfusions before 1992)
Hepatitis C DX
HCV RNA more sensitive than HCV Ab
Porcelain gallbladder considered
Premalignant-associated with chronic cholecystitis and gallbladder
Acute acalculous cholecystitis
Seen in the acutely ill 2º to dehydration, prolonged fasting, TPN
● Due to gallbladder sludge, not stones
Acute Hep almost always converts to chronic true or false?
True; may eventually progress to cirrhosis and liver failure
Which hepatitis is only DNA virus?
Hep B ; blood borne,
Hep D is always associated with ?
Hep B
Treatment for Hep B?
Interferon-alpha, Lamivudine, vaccinatinos for A and flu yearly and void Etoh
Increase risk for primary hepatocellar carcinoma ?
Hep C
Chronic can be asymptomatic for years?
Hep C
High infant mortality rate in pregnant woman?
Hep E; fecal oral and self limiting dz
What is Fulminant Hepatitis ?
Rapid liver failure + encephalopathy
● Acute w/in 8 weeks of liver injury onset
Number cause for fulminant hepatitis ?
#1 cause acetaminophen; drug reactions (isoniazid, rifampin), viral hepatitis, Reye syndrome (#1 in kids associated with asa use in viral illnesses),
s/s fulminant hepatitis ?
S/S: Encephalopathy, vomiting, asterixis, hyperreflexia, coagulopathy, jaundice
Dx fulminant hepatitis ?
Dx: ↑ ammonia, ↑PT/INR, hypoglycemia, ↑LFTs
TX fulminant hepatitis ?
Tx: Lactulose for hepatic encephalopathy, liver transplant is definitive
Acute cholecystitis culprits ?
Gram neg enteric bacteria ( E. coli, Klebsiella, Enterobacter
Acute cholecystitis PE?
Fever, + Murphy’s sign, + Boas’ sign (R shoulder pain d/t phrenic nerve
irritation)
Acute cholecystitis #1 dx imaging?
U/S Distended gallbladder, gallstones, + sonographic Murphy’s sign; HIDA scan if U/S equivocal
Acute cholecystitis dx labs?
↑WBC, ↑bilirubin, ↑Alk phos
Hida Scan /PIPIDA -Nuclear scan of gall bladder negative test? positive test?
Negative test-GB lights up =can make sx elective; Positive-GB not seen =SX
Acute cholecystitis tx?
NPO, IV fluids, antibiotics, cholecystectomy
○ Ceftriaxone + metronidazole, piperacillin/tazobactam
Acute causes for pancreatitis? In Kids?
Causes: #1 gallstones (40%) and #2 alcohol (35%); medications, iatrogenic d/t
ERCP, malignancy, scorpion bite, cystic fibrosis, MUMPS IN KIDS
S/S of Acute pancreatitis?
Epigastric pain: Constant, boring, radiating to back, relieved by leaning
forward
○ N/V
○ Fever
PE of Acute pancreatitis?
PE: ± epigastric tenderness, tachycardia, ↓ bowel sounds
■ If necrotizing, hemorrhagic: Cullen’s sign (periumbilical ecchymosis)
Grey Turner sign (flank ecchymosis)
What criteria is used to dx Acute pancreatitis?
RAnson’s criteria can be used for prognosis
Labs for Acute pancreatitis?
Lipase: More specific than amylase, rises first and elevated longer as
compared to amylase
■ Amylase: >3x upper limit of normal (ULN) suggestive but not as
specific
■ ALT: >3x ↑ suggestive of gallstone pancreatitis
■ ↑WBC, ↑glucose, ↑bilirubin, ↑triglycerides
■ Hypocalcemia
DX test of choice for Acute pancreatitis?
CT *diagnostic test of choice
TX for Acute pancreatitis?
90% recover without complications and only require “pancreas rest”
○ Supportive: IV fluids, NPO, pain control
○ Abx not routinely used; if severe/necrotizing use broad spectrum
What is Chronic pancreatitis?
Chronic inflammation causing parenchymal destruction and fibrosis which results
in loss of exocrine and sometimes even endocrine function
What is Ranson’s Criteria?
At admission, score ≥ 3 = severe pancreatitis likely ○ Age > 55yr ○ Glucose > 200 mg/dL ○ LDH > 350 IU/L ○ AST > 250 IU/dL ○ WBC > 16,000 ● At 48 hours, combined with the admission 5 suggestive of mortality (score >4 significantly increased mortality: 5 to 6 (40%); 7 to 8 (100%)) ○ Calcium <8.0 mg/dL ○ Hematocrit fall > 10% ○ Oxygen PO2 < 60 mmHg ○ BUN > 5 mg/dL after IV fluids ○ Base deficit >4 mEq/L ○ Sequestration of fluid > 6L
Causes of Chronic Pancreatitis in adults ?
Causes: #1 alcohol abuse, idiopathic, familial, hyperlipidemia
Causes of Chronic Pancreatitis in kids ?
cystic fibrosis #1 in
kids
Triad of calcifications, steatorrhea, DM; also weight loss
Chronic Pancreatitis
chain of lakes” on CT and calcified pancreas?
Chronic Pancreatitis
TX for Chronic Pancreatitis
Oral pancreatic enzyme replacement, pain control, alcohol abstinence
Anal abscess/fistula (Level 1) culprits?
Staph aureus, E. coli, Bacteroides
Anal fistula?
open tract, seen especially with deeper abscesses;S/S: Snal discharge and pain
Anal abscess/fistula (Level 1) Tx
I&D then “WASH”; W arm water cleansing
○ A nalgesics
○ S itz baths
○ H igh fiber diet
Anal fissure (Level 2)? s/S?
Painful linear tear in distal anal canal
● Cause: Anal trauma, passage of large/hard stools, low fiber diet
● S/S: Severe rectal pain with bowel movements so patient may avoid BM causing
constipation, BRBPR
○ PE: Most common at posterior midline, skin tags may be present if chronic
Anal fissure (Level 2) TX?
> 80% resolve spontaneously
○ Supportive measures: Warm Sitz baths, pain meds, high fiber diet, stool
softeners
○ 2nd line: Topical vasodilators
Appendicitis (Level 3) s/s?
S/S: Anorexia, “hamburger sign” (patient does not want to eat), epigastric pain
which moves to RLQ, N/V, fever
Appendicitis (Level 3) PE:
Rovsing sign: Palpation in LLQ elicits RLQ pain (looks like the word roving so
roving pain)
○ Obturator sign: Internal and external hip rotation with flexed knee elicits
RLQ pain
○ Psoas sign: Right hip flexion/leg raise against resistance elicits RLQ pain
○ McBurney’s tenderness: Pain at point ⅓ distance from ASIS and navel
Appendicitis (Level 3) DX?
CT scan, U/S, ↑WBC
Appendicitis (Level 3) TX?
NPO, IV fluids, anaerobic and gram neg antibiotic coverage (simple appendicitis
Ertapenem OR Metronidazole + Ceftriaxone), appendectomy
Appendicitis (Level 3) Complications?
Perforation or Abscess
○ Perforation: Abx until afebrile with normal WBC and then appendectomy
with delayed primary skin closure
○ Abscess: Abx and percutaneous drainage with delayed appendectomy
What is Celiac Dz?
Small bowel autoimmune inflammation 2º to gluten causes loss of villi and
absorptive area
● Women > Male
What is Celiac s/s?
Malabsorption: Diarrhea, abdominal pain, distention, bloating, steatorrhea; And Dermatitis herpetiformis
pruritic, papulovesicular rash on extensors, neck,
trunk
Dermatitis herpetiformis
Celiac Dz Dx?
+ endomysial IgA Ab, + transglutaminase Ab, small bowel bx
Pediatric foreign body ingestion Common ages? Common items?
6MO-3YO
Common items: #1 coins, button batteries, pins, toys/toy parts, magnets, marbles,
screws
Magnets (pediatric foreign body ingestion?
High powered magnets can cause GI perforation
■ Ingestion of 2+ magnets can lead to attraction across bowel layers
causing pressure necrosis, fistula, perforation
■ Single magnets may be managed conservatively
● Keep child away from magnetic materials until it passes
Button batteries (pediatric foreign body ingestion?
Chemical content, diameter and height of battery is imprinted code
on battery
● Eg CR2032 (Content: Lithium/manganese dioxide Diameter in
mm: 20mm; Height in tenths of mm: 3.2 mm)
■ Damage depends on how long since ingestion, size of battery,
amount of charge left
■ Esophageal injury d/t pressure necrosis
■ Stomach acid can dissolve seal of battery causing chemical release
■ Most serious injuries have diameter >20mm
■ NPO during evaluation
■ Removal necessary of all batteries in esophagus and anywhere if
patient has symptoms
3rd most common cause of cancer death worldwide,
Stomach Cancer: 15th in US
Stomach Cancer risk factors?
tobacco, alcohol, high nitrite diet, H. pylori; Men:Women 2:1; Most common type = adenocarcinoma
MC type of stomach cancer?
adenocarcinoma
Stomach cancer Clinical features
Symptoms = advanced disease
o Anorexia, indigestion, nausea, vomiting, dysphagia, weight loss, melena, early satiety
o Later Sx – effusions (pleural & peritoneal), obstruction, jaundice
● May palpate an enlarged stomach, anterior axillary nodes, supraclavicular nodes (Virchow
node), periumbilical nodule (Sister Mary Joseph nodule [umbilical metastasis])
Stomach Cancer Workup
CBC (iron de), CMP, CEA (50%) & CA 19-9 (20%)
EGD FOR TISSUE DX-ADENOCARCINOMA (90-95%)
Stomach cancer TX:
Surgical resection ± nodal resection
o Most surgically resected patients will have a recurrence
● Multiple chemo regimens available (commonly used given typical advanced presentation)
Pyloric Stenosis
Hypertrophy of pyloric muscle (usually first 4-6 weeks of life)
● Sx: projectile vomiting
● PE: mobile “olive” mass in epigastrum
● Dx: string sign on barium swallow (ultrasound may be preferred initial study)
● Tx: pylorotomy
What is Cholangitis (Level 1)
Infection of biliary tract 2º to obstruction from gallstones, malignancy
Culprits Cholangitis (Level 1)
Gram neg enteric bacteria ( E. coli, Klebsiella, Enterobacter )
s/s of Cholangitis (Level 1)
Charcot’s triad: Fever/chills, RUQ pain, jaundice
○ Reynold’s pentad: Charcot’s Triad + shock + AMS(altered mental status)
DX Imaging of Cholangitis (Level 1)? Labs?
CHOLANGIOGRAPHY GOLD STANDARD via ERCP or PTC (percutaneous
transhepatic cholangiography)-Done usually after patient afebrile/stable x 48 hours on Abx; U/S and CT -show dilation of common bile duct; Elevated liver enzymes (ALT/AST/Alk phase/GGT), Bilirubin and WBC.
TX of Cholangitis (Level 1)
Ampicillin/sulbactam, piperacillin/tazobactam
○ Common bile duct decompression/stone extraction via ERCP
○ Open surgical decompression
What is Cholelithiasis (Level 2)
gallstones, no inflammation
RF of Cholelithiasis (Level 2)
The 5 Fs” fat, fair, female, forty, fertile
○ Also Native Americans, cirrhosis, bile stasis, ↑triglycerides
Dx of Cholelithiasis (Level 2)
Dx: Ultrasound *gold standard
TX of Cholelithiasis?
surgery if symptomatic,Observation if asymptomatic
Complications of Cholelithiasis
Choledocholithiasis, acute cholecystitis, acute cholangitis
Choledocholithiasis,
resence of stones in bile ducts; the stones can form in the gallbladder or in the ducts themselves. These stones cause biliary colic, biliary obstruction, gallstone pancreatitis, or cholangitis (bile duct infection and inflammation).
Chronic hepatitis (Level 1)
Disease > 6 mo; Leads to end-stage liver disease (ESLD) or hepatocellular carcinoma (HCC)
Common causes of Chronic hepatitis (Level 1)
Chronic viral infection, alcohol, autoimmune, WILSON’S DISEASE,
HEMOCHROMATOSIS, alpha 1 antitrypsin deficiency; 10% HBV, 80% HCV become chronic (also HDV can become chronic)
Chronic hep labs?
Labs AST/ALT elevated but < 500;
Autoimmune hepatitis: + Anti smooth muscle Ab
○ Wilson’s disease: Low ceruloplasmin, high urine copper
■ Kayser Fleischer rings: Copper deposits in cornea
○ Hemochromatosis: High ferritin, transferrin saturation >50%
Chronic Hep B
↑ risk HCC
● 90% perinatally acquired
● Chronic asymptomatic carrier: +HBsAg, +HBeAb with normal labs, undetectable
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HBV DNA, normal liver bx → can still transmit to others
● Chronic infection: +HBsAg, ↑ AST/ALT, ↑HBV DNA, damage seen on liver bx
Chronic Hep C- unique testable facts
Serologic markers of chronic infection: HCV RNA and Anti HCV
● CDC recommends 1-time screening for all adults born between 1945-1965,
regardless of risk factors
What is Cirrhosis (Level 1)
Irreversible liver fibrosis with nodules caused by chronic liver disease
S/S of Cirrhosis (Level 1)
Constitutional: Fatigue, weight loss, anorexia, weakness
○ PE: Ascites, hepatosplenomegaly, gynecomastia, spider angioma, caput
medusa, bleeding due to ↓ coagulation factors, jaundice, pruritus
○ Hepatic encephalopathy: Confusion, lethargy
■ Asterixis, ↑ ammonia because liver cannot clear it
○ Esophageal varices
○ Spontaneous bacterial peritonitis
DX of Cirrhosis (Level 1)
U/S, liver biopsy, LFTs
Tx of Cirrhosis (Level 1)
Hepatic encephalopathy: Lactulose to pull ammonia into gut, causes
diarrhea
○ Ascites: Na⁺ restriction, diuretics, paracentesis
○ Pruritus: Cholestyramine to ↓ bile salts in the skin
○ Definitive management liver transplant
● Screen for HCC with U/S and alpha-fetoprotein
Causes of Cirrhosis (Level 1)
#1 alcohol, chronic viral hepatitis, non-alcoholic fatty liver disease, hemochromatosis, autoimmune hepatitis, primary biliary cirrhosis, drug toxicity
What is Colon cancer (Level 1)? Risks?
3 in US cancer deaths
● Progression from adenomatous polyp to adenocarcinoma usually 10-20 years
● #1 MET LOCATION IS LIVER
Risks: Familial adenomatous polyposis, age > 50yr, Ulcerative colitis > Crohn
disease, adenomatous polyps , low fiber diet, smoking, alcohol, AA, family history
S/S of Colon cancer (Level 1)
Iron deficiency anemia, rectal bleeding, abd pain, change in bowel habits
○ #1 cause of large bowel obstruction
○ R sided masses tend to bleed causing anemia and + fecal occult blood,
diarrhea
○ Left sided masses tend to cause obstruction, present later, change stool
diameter, hematochezia
DX of Colon cancer (Level 1)
Colonoscopy with biopsy, barium enema showing “apple core lesion” , CBC, CEA
TX of Colon cancer (Level 1)
Tx:
○ Stage I-III; localized: surgery
○ Stage III + mets: chemotherapy/5-FU
Screenings of Colon cancer (Level 1)
USPSTF recommendations start at age 50yr
■ High sensitivity fecal occult blood testing annually
■ Colonoscopy every 10yr from 50-75yr
■ Flex sig every 5yr with FOBT every 3yr
○ If 1st degree relative with colon cancer, screening starts at 40yr or 10 years
before relative’s diagnosis
Causes of Constipation (Level 3)
1 inadequate fiber/fluid, poor bowel habits
○ Systemic: DM, hypothyroidism, Parkinsons, MS, hypokalemia
○ Meds: Opioids, calcium channel blockers, anticholinergics, psychotropics
○ Structural: Tumor, stricture, Hirschsprung disease
○ Slow colonic transit: Psychogenic, eating disorders
○ IBS
○ Pelvic floor dyssynergia
Alarm S/S of Constipation (Level 3)
Hematochezia, weight loss, anemia, + FOBT (fecal occult blood
test)
TX Constipation (Level 3)
Fluids
○ Fiber: Retains water and improves transit
○ Bulk forming laxatives: absorbs water and increases fecal mass, softens
stool
■ Most physiologic and effective tx
○ Osmotic laxatives: Pulls water into gut and stool
○ Stimulant laxatives: ↑ peristalsis and alters electrolyte transport in the
mucosa
When to refer for Constipation (Level 3)
For colonoscopy if alarm symptoms or >50yr
○ For biofeedback therapy if defecatory disorder
○ For anorectal testing if refractory constipation
Diverticula:
Herniation of the mucosa into the colonic wall causing outpouching
○ Most common at sigmoid colon due to high intraluminal pressure
Diverticulosis:
Non-inflamed diverticula
○ Usually asymptomatic#1 cause of acute lower GI bleeding
Diverticulitis:
Inflamed diverticula
○ S/S: Presents like appendicitis mimic on the left, fever, LLQ pain, N/V,
diarrhea/constipation, bloating
Dx of Diverticulitis/diverticulosis
CT scan
○ ↑ WBC in acute phase (diverticulitis)
○ + guaiac (diverticulosis)
Tx of Diverticulitis/diverticulosis
Diverticulosis: High fiber diet, bleeding typically self limited
○ Diverticulitis: Bowel rest, clear liquid diet, antibiotics (Ciprofloxacin or
TMP/SMX, plus Metronidazole)
