GI

Question 1

The physiology of bile metabolism may be altered in three principal areas:

Answer 1

(1) overproduction of heme products (hemolysis)
(2) failure of the hepatocyte to take up, conjugate, and excrete bilirubin (hepatocellular dysfunction)
(3) obstruction of biliary excretion into the intestine.

Question 2

Which is more dangerous, Conjugated or Unconjugated bilirubin?

Answer 2

Unconjugated bilirubin that is
not bound to albumin can cross the blood-brain barrier, causing
adverse neurologic effects ranging from subtle developmental
abnormalities to encephalopathy and death.

Question 3

New onset painless jaundice is the classic presentation of

Answer 3

Neoplasm involving the head of the pancreas

Question 4

Indirect > Direct bilirubin suggests what pathology(s)

Answer 4

Hematologic cause

Would expect normal transaminases, alk phos, PT/PTT

Question 5

Direct > Indirect bilirubin suggests what pathology(s)

Answer 5

Hepatobiliary pathology

#Obstructive: biliary stones, benign/malignant stenosis
Elevated alk phos

#Hepatocellular/Cholestatic:
Transaminitis, elevated PT

Question 6

Triad of Acute Hepatic Failure

Answer 6

Jaundice
Encephalopathy
Coagulopathy (INR >1.5)

Question 7

Rapid development of ascites and hepatomegaly suggests what diagnosis

Answer 7

Portal Vein Thrombosis (Budd Chiari Syndrome)

Question 8

Diagnosis of SBP via paracentesis

Answer 8

Presence of more than 250 polymorphonuclear cells
per cubic millimeter of ascitic fluid is diagnostic for SBP
(ie >250 neutrophil count)

Question 9

What medication has been shown to INCREASE mortality in SBP

Answer 9

Beta blockers

Question 10

Where is jaundice first apparent?

Answer 10

Jaundice is first apparent sublingually, in the conjunctiva and on the hard palate.

Question 11

Treatment of SBP

Answer 11

Cefotaxime 2g

Question 12

Idiopathic cause of jaundice in 3rd trimester of pregnancy

Answer 12

Intrahepatic cholestasis of pregnancy

Question 13

Blood transfusion is immediately indicated in patients with GI bleed who have

Answer 13

hemoglobin level acutely less than 7 to 8 g/dL, are experiencing vigorous blood loss, or require further resuscitation beyond 2 L of crystalloid to maintain a systolic blood pressure in the range of 100 mm Hg

Question 14

What clinical scoring systems can be used to aid disposition in upper GI bleed

Answer 14

Blatchford Score

Rockall Scoring system

Question 15

empirical treatments for systemically

ill appearing adults with suspected traveler’s diarrhea

Answer 15

Ciprofloxacin 500 mg orally twice daily or levofloxacin (Levaquin) 500 mg once daily

Question 16

C. difficile treatments

Answer 16

metronidazole 500 mg orally three

times daily for 10 to 14 days as initial treatment or vancomycin 125 mg four times daily orally for 10 to 14 days.

Question 17

dysphagia differential

Answer 17

Dysphagia can be caused by:

# obstructive lesions (aortic aneurysm)
# motility disorders (achalasia)
# neuromuscular disorders that can
be vascular (eg, cerebral vascular accident), immunologic (eg, multiple sclerosis [MS]), infectious (eg, botulism), or metabolic

Question 18

Abx for esophageal perforation

Answer 18

broad-spectrum antibiotics (eg, vancomycin, 15 mg/

kg and piperacillin-tazobactam, 3.375 g)

Question 19

First Line treatment for H. Pylori

Answer 19

PPI (eg, omeprazole, 20 mg bid), amoxicillin (1 g bid) and clarithromycin (500 mg bid) for 14 days.

Question 20

Pathonomonic triad (Mackle’s triad) for upper esophageal perforation

Answer 20

emphysema, chest pain, and vomiting

Question 21

GERD Tx

Answer 21

H2 blockers (mild-to-moderate GERD)

The only lifestyle recommendations that have evidence based support are weight loss and head of bed elevation

#PPI (A Cochrane systematic
review has concluded that PPIs are more effective than H2 blockers in eliminating symptoms and healing mucosal damage)

Sucralfate is a mucosal protectant that binds to inflamed tissue to create a protective barrier. It blocks the diffusion
of gastric acid and pepsin across esophageal mucosa and can limit the erosive action of pepsin and bile. It has limited side effects and can be safely used in pregnant women.

Question 22

Treatment regiments for pyogenic abscess

Answer 22

• Cefotaxime + metronidazole
• Ampicillin + gentamycin + metronidazole
• Ciprofloxacin or levofloxacin or moxifloxacin + metronidazole
• Piperacillin-tazobactam
• Impinem or meropenem, or doripenem or ertapenem

• Definitive treatment for abscesses larger than 3 cm includes image-guided percutaneous drainage.

Question 23

How do you differentiate amebic from pyogenic liver abscesses

Answer 23

Amebic Abscess
• Although similar in many ways to pyogenic abscess, diagnosis is made via stool analysis or ELISA testing.
• Most patients will have elevation in alkaline phosphatase and aminotransferase levels.
• Ultrasound may reveal specific findings unique to an amebic abscess, including a peripherally located abscess with a well-circumscribed boarder and a homogeneous, hypoechoic center.

Question 24

Treatment for amebic liver abscess

Answer 24

IV or oral metronidazole (750 mg tid for 7–10 days).

Question 25

Abx for cholecystitis

Answer 25

IV piperacillin-tazobactam (3.375 g qid) Combination therapy with a third-generation cephalosporin and metronidazole or monotherapy with a carbapenem or β-lactamase inhibitor is recommended

Question 26

In actively bleeding cirrhotic patients with liver-associated coagulopathies, which is preferred - cryoprecipitate or FFP?

Answer 26

Cryoprecipitate, 1 unit/10 kg body weight

Question 27

What medication classes should be avoided in Cirrhotic patients?

Answer 27

Angiotensin-converting enzyme inhibiting drugs and angiotensin receptor blocking drugs should be avoided in patients with cirrhosis. Both lower mean arterial blood pressure and may increase mortality.

Question 28

Management of hepatorenal syndrome?

Answer 28

norepinephrine, 0.5–3 mg/h in combination with albumin 1 g/kg (maximum, 100 g).

Question 29

What underlying conditions can exacerbate hepatic encephalopathy

Answer 29

GI bleeding, hypokalemia, infection and dehydration

Question 30

What is the sensitivity and specificity of CT for cholecystitis

Answer 30

Sensitivity: 92% Specificity: 99%

Question 31

Abx for cholangitis

Answer 31

FIRST-LINE SINGLE-DRUG REGIMEN Ampicillin-sulbactam 3 g IV qid Piperacillin-tazobactam 3.375 g IV qid FIRST-LINE MULTIDRUG REGIMEN Ceftriaxone + Metronidazole 1 g IV every 24 h + 500 mg IV tid

Question 32

Schatzki's ring

Answer 32

Frequently found in patients with impacted food boluses. Ring of muscular tissue in the esophagus that causes dysphagia. Dx via upper endoscopy and frequently a/w hiatal hernia

Question 33

Difference in Location of Mallory-Weiss tear vs Boerhaave's syndrome

Answer 33

MW: gastro-esophageal junction BS: unsupported left posterolateral wall of distal esophagus ** Iatrogenic esophageal rupture often occurs in proximal esophagus**

Question 34

PUD: Gastric vs Duodenal Which is associated with weight loss?

Answer 34

Gastric ulcer -> pain right after eating, gets worse with food, therefore, a/w weight loss *Duodenal: pain 2-3 hours after eating, gets better with food

Question 35

PUD: Gastric vs Duodenal Which is more likely to bleed

Answer 35

Duodenal ulcer 2x more likely to bleed

Question 36

PUD: Gastric vs Duodenal Which increases risk for cancer?

Answer 36

Gastric Biopsy should be done during endoscopy to rule out malignancy *Duodenal does not lead to cancer, biopsy is unnecessary

Question 37

Treatment for NSAID-induced gastric ulcer

Answer 37

misoprostol

Question 38

Osler-Weber-Rendu Syndrome

Answer 38

Autosomal Dominant Epistaxis is most common presentation A/W telangiectasis of the skin, mucous membranes, GI tract causing recurrent GI bleeding

Question 39

Which Hepatitis progresses to chronic infection

Answer 39

Hepatitis C: 50% will develop chronic infection Hepatitis B: small chance

Question 40

Hepatitis serum marker: Indicates acute infection

Answer 40

HbcAb IgM

Question 41

Hepatitis serum marker: Hallmark for diagnosis; appears 1-10 weeks after exposure and is positive even before liver enzymes start to increase

Answer 41

HBsAg

Question 42

Hepatitis serum marker: Indicates immunity; persists for life; signs of previous infection or vaccination

Answer 42

HBsAb

Question 43

Most common isolated organism in SBP

Answer 43

E. Coli

Question 44

What lab value can help identify etiology of pancreatitis

Answer 44

ALT Low sensitivity but high specificity for biliary etiology

Question 45

Ranson's criteria: Prognostic indicator for inpatient mortality for acute pancreatitis. Criteria at admission?

Answer 45

On admission: ``` Age > 55 WBC > 16 Glucose > 200 AST > 250 LDH > 350 ```

Question 46

Bowel sounds in Ileus vs SBO

Answer 46

Ileus: HYPOactive SBO: HYPERactive

Question 47

Treatment of Ogilvie Syndrome

Answer 47

Colonic decompression and Neostigmine *Acute colon pseudo-obstruction secondary to autonomic dysfunction leading to massive dilation of colon (>10cm). No mechanical obstruction.

Question 48

Treatment for Travelers diarrhea (ETEC)

Answer 48

Single dose of Cipro Unless: children, pregnant, pt just returned from SE asia (where campylobacter is more common) --> single dose of azithromycin

Question 49

Differentiate Vibrio vulnificus and vibrio parahaemolyticus

Answer 49

both a/w raw oysters and seafood vulnificus: characteristic skin findings and more aggressive parahaemolyticus: no skin findings, self-limited

Question 50

Test of choice for Giardia

Answer 50

Stool antigen | not stool for ova or parasites

Question 51

Rectal prolapse in a child can be a sign of...

Answer 51

Cystic Fibrosis

Question 52

When clinicians have a low pretest possibility for appendicitis, what lab values support the exclusion of appendicitis as a likely diagnosis

Answer 52

When clinicians have a low pretest possibility for appendicitis, the combination of a WBC count below 10,000/mm3 and CRP level below 8 mg/L support the exclusion of appendicitis as a likely diagnosis.

Question 53

What is the most common cause of bacterial enteritis in developed countries.

Answer 53

Campylobacter

Question 54

What is the most common cause of acute gastroenteritis in children and adults

Answer 54

The norovirus, previously referred to as the Norwalk-like virus, is the most common cause of acute gastroenteritis in children and adults and usually occurs in the winter months.

Question 55

Risk factors for C. Diff

Answer 55

``` # recent antibiotic use (1–4 weeks) # recent hospitalization # living in a long-term care facility # use of antacids. ```

Question 56

Diagnosis consideration? Diarrhea lasting more than 2 weeks, with foul-smelling stools and symptoms of flatulence, abdominal bloating, cramping, and recent exposure to contaminated river water

Answer 56

Giardia

Question 57

What is dysentery

Answer 57

refers to an inflammation of the intestine, particularly the colon, causing diarrheas associated with blood and mucus; it is generally associated with fever, abdominal pain, and rectal tenesmus (sense of incomplete defecation).

Question 58

Historical feature that distinguishes Crohn's disease from IBD

Answer 58

Nocturnal diarrhea