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GI Flashcards

1
Q

Associations with PPI

A 
HypoMg
Low B12
C.diff
Pneumonia
AIN
Dementia
CKD
Low BMD
Gastric CA
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2
Q

Treatment Barrett’s Esophagus

A

Dysplastic: Endoscopic eradication + PPI

Non-dysplastic: PPI OD, rpt OGD 3-5 years

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3
Q

Dysphagia alarm symptoms (warrants OGD)

A 
Weight loss,
Anemia
Hematemesis/Melena
Onset >age 50
Emesis 
Odynophagia
Persistent dysphagia despite PPI BID

*No alarm sx and <50yo + GERD –> PPI trial

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4
Q

Diagnostic Test for Achalasia

A
  1. EGD to r/o pseudo-achalasia aka obstruction from Ca; narrow GEJ with dilated esophagus
  2. Manometry (gold standard - shows impaired relaxation or abnormal peristalsis) > barium swallow (shows bird beak)
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5
Q

Treatment Achalasia

A

Good surgical candidate:

  • Pneumatic dilatation (type 1+2) - risk of tear
  • Laparascopic heller myotomy +/- fundoplication
  • POEM (peroral endoscopic myotomy)
  • Esophagectomy - if failed above or sigmoid- or mega - esophagus

Poor OR candidate: Endoscopic botox > CCB/ nitrates eg nifedipine or ISDN

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6
Q

Risk factors for eosinophilic esophagitis

A

Male
Young (20-30)
Allergy/Atopy, Eczema, Asthma
Chronic rhinitis

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7
Q

Secondary causes of eosinophilic esophagitis

A 
Pill esophagitis
CTD
Hypermobility syndromes
HyperIgE syndrome
Pemphigus
Untx Achalsia
Untx GERD
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8
Q

Treatment eosinophilic esophagitis

A
  • 6 food elimination diet (eggs, soy, cow’s milk, wheat, tree nuts, seafood)
  • 1st line = Topical swallowed steroid (fluticasone, budesonide)
  • 2nd line = pred
  • Consider dilation if symptomatic strictures
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9
Q

Complications of celiac disease

A

Malnutrition: weight loss, vitamin and mineral deficiency: Fe/B12 (anemia), Ca/vit D (osteoporosis),
Mild transaminitis
Dermatitis Herpetiformis (Dapsone after r/o G6PD)
Enteropathy associated T-cell lymphoma (consider if pt stops responding to gluten fee diet)

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10
Q

Celiac disease: Work-up

A

If high prob: OGD with duod bx + anti-TTG IgA +/- IgA

If low prob: 1st Anti-TTG IgA +/- IgA

  • If high TTG IgA –> OGD with bx
  • If normal TTG IgA and low serum IgA –> TTG IgG –> If positive proceed to OGD with bx
  • If normal TTG IgA and normal IgA –> no celiac

If Bx + Anti-TTG IgA (or IgG if IgA deficient) + = CD
If both neg = no celiac
If Bx + TTG discordant-> HLADQ2/DQ8 to r/i or r/o

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11
Q

Indications to order HLA DQ2/DQ8 for Celiac Disease

A

Discordant biopsy and anti-TTG
Patient unable to comply with gluten-rich diet x3 months
Down Syndrome

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12
Q

Foods included in gluten free diet

A

BROW

Barley
Rye
Oats
Wheat

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13
Q

Pathology in Crohn’s vs UC

A

Crohn’s: Gum to bum (MC small bowel, ileocolitis, colonic)
Transmural inflammation, non-caseating
Skip lesions “cobblestone mucosa”
Strictures, Fistulas, clubbing

UC: Extends from rectum proximally
Submucosal/mucosal inflammation
Crypt distortion/atrophy/abscess
Contiguous, rare clubbing

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14
Q

Complications in Crohn’s vs UC

A

Crohn’s:

  • Fistulas (intra-abdo, perianal)
  • Abscess (intra-abdo, perianal)
  • Strictures (cold/hot) and obstruction
  • Peri-anal disease
  • CRC

UC:

  • Toxic megacolon
  • Colonic perforation
  • Refractory bleeding
  • CRC
  • Cholangiocarcinoma
  • PSC
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15
Q

Induction Treatment Crohn’s Disease

A

Mild-Mod: Budesonide (if terminal ileum +/- R colon), Pred (colon only). **No role for 5ASA or thioprine

Mod-Severe:

  • Prednisone/Methylpred 40-60/d if low risk
  • Anti-TNF + AZA or MTX +/- Pred/Methylpred if high risk (if already failed anti-TNF, vedolizumab or ustekinumab acceptable)
  • always start TNFi with thioprine
  • check TMPT before starting AZA/6MP
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16
Q

Induction Treatment UC

A

Mild: Budesonide or 5-ASA (PO if extensive, PR enema if left sided colitis - sigmoid to splenic flexture, PR supp if proctitis <18cm)

Mod-Severe: Budesonide or Pred/Methylpred or anti-TNF (vedolizumab, ustekinumab, TNFi, JAK-2i acceptable if failed TNF)

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17
Q

Maintenance Treatment Crohn’s Disease

A

Mild-Moderate: Thioprine

Moderate-Severe: 
- Thioprine
- MTX 
- Anti-TNF (with Aza or MTX)  - *esp if fistulas
- Anti-integrin (Vedolizumab)
- AntiIL12/23 (Ustekinumab)
NO JAKi (ONLY UC)
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18
Q

Maintenance Treatment UC

A

Mild: 5-ASA (PO/PR enema/PR sup)

Moderate-Severe:

  • 5-ASA
  • Azathioprine or 6-MP
  • Anti-TNF (with Aza or MTX)
  • Anti-integrin (Vedolizumab)
  • AntiIL12/23 (Ustekinumab)
  • JAK-2 inhibitor (Tofacitinib, Barocitinib)
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19
Q

Treatment Crohn’s Disease Complications

A
  • If fever - always R/O infxn with Cx +/- MRE/CTE (intra-abdo abscess) +/- EUS/MRI pelvis (perianal abscess)
  • Perianal fistula: Anti-TNF + Thioprine/MTX (+surgery if intraabdo)
  • Perianal Abscess: I&D (or surg if intraabdo) + Cipro/flagyl
  • Cold Stricture: Conservative tx +/- endo dilatation/surgery
  • Hot Stricture: Steroid induction –> biologic maintenance
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20
Q

Classifying UC Severity

A 
Mild: 
<4BMs/day
Intermittent blood only
Normal Hgb
ESR <30 
Severe:
Vitals: T>37.8C, HR >90
>6BMs/day
Frequent blood 
Low Hgb (<105)
ESR >30
Dehydration requiring hospitalization
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21
Q

Definition Toxic Megacolon in UC

A
  1. Megacolon > 6cm +
  2. > =3 of: Fever >38, HR >120, Anemia, Neuts >10.5 +
  3. > =1 of: Dehydration, Lyte abn, hypotension, altered LOC
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22
Q

UC: Indications for colectomy

A
  1. Toxic megacolon
  2. Severe bleeding
  3. Perforation
  4. Flare refractory to medical tx x3-5 days
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23
Q

Diagnostic tests for H. Pylori

A

Biopsy histology
Biopsy culture
Stool Ag
Urea breath test

*Serology does not differentiate current vs prior infxn

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24
Q

Treatment H. Pylori

A

1st Line: PBMT x 14 days = PPI + Bismuth + Metronidazole + Tetracycline
OR
PAMC x 14 days = PPI + Amox + Metronidazole + Clarithro
Treatment failure: PBMT (if prior triple therapy) or PAL x14d (PPI/Amox/Levo)

*Urea breath test, biopsy, or stool Ag (NOT serology) >4 weeks post completion of tx

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25
Q

DDX Lower GI Bleed

A

Painless: Diverticular, hemorrhoids, polyp, CA, angiodysplasia, radiation proctitis or colitis, (IBD, infectious)

Painful: Ischemic colitis (low flow, atherosclerotic), Mesenteric (cardioembolic), thrombosed hemorrhoid, fissure, (IBD, infxn)

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26
Q

DDX Hepatocellular transaminitis in 1000s

A 
Acetaminophen
AI Hepatitis
Viral hepatitis (A, B, D, E)
Ischemic hepatitis (Shock liver, Budd Chiari)
Acute Stone w/i 24h
Wilson's (rare)
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27
Q

DDX Hepatocellular transaminitis in 100s

A

Alcohol (AST/ALT >2; unlikely if LE >300)
Drugs (tyl, MTX, anti-thyroid, ABX)
Viral (Hep B, C, EBV, CMV)

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28
Q

DDX Hepatocellular transaminitis <100

A 
NASH 
Celiac
Hemochromatosis
Wilsons
A1AT
Drugs
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29
Q

DDX Cholestatic Transaminitis

A

Extra-hepatic:

  • Stone
  • PSC stricture
  • Benign obstruction (IgG4/AIP, AIDS cholangiopathy)
  • Malignant obstruction (pancreatic CA, cholangioCA)

Intra-hepatic:

  • PBC
  • Drugs (ABX, TPN, Estrogen, MTX)
  • IHCP
  • Hepatic infiltration
  • Infection
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30
Q

Hepatitis B Serology: Immune from past infection

A

SAg - , SAb + , cIgM -, cIgG + , EAg - , EAb + , DNA neg

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31
Q

Hep B Serology: Immune from vaccine

A

SAg - , SAb +, cIgM - , cIgG -, EAg -, EAb - , DNA neg

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32
Q

Hep B Serology: Window Period

A

SAg- , SAb - , cIgM + , cIgG -, EAg +/- , EAb -/+, DNA neg

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33
Q

Hep B Serology: Acute infection

A

SAg+, SAb -, cIgM +, cIgG +/-, EAg +, EAb - , DNA pos

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34
Q

Hep B Serology: Chronic Infection (<5% with HepB) - 4 categories

A

1) EAg + chronic infection (Immune Tolerant):
SAg+, SAb-, cIgM-, cIgG +, EAg +, EAb -, DNA >1 mill
ALT normal, no fibrosis on biopsy or fibroscan

2) EAg + chronic hepatitis (Immune active):
SAg+, SAb-, cIgM-, cIgG +, EAg +, EAb -, DNA> 20,000
ALT elevated (>2x ULN), mod-sev inflmn/fibrosis on bx or fibroscan

3) EAg - chronic infection (inactive carrier):
SAg+, SAb-, cIgM-, cIgG +, EAg -, EAb +, DNA <2000
ALT normal, minimal fibrosis/inflmn on bx or fibroscan

4) EAg - chronic hepatitis (immune reactivation):
SAg+, SAb-, cIgM-, cIgG +, EAg -, EAb +, DNA >2000
ALT elevated, fibrosis/inflmn on bx or fibroscan

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35
Q

HepB Antiviral Treatment: Indications

A

Acute: Only if progressive liver failure

Chronic: (goal convert sAg and EAg –> Ab, dec DNA lvl and risk cirrhosis/HCC)

  • Immune active: EAg+, ALT >2x ULN, + DNA >20,000
  • Immune reactivation: EAg -, ALT >2x ULN, + DNA >2000
  • Cirrhosis
  • Fibrosis >stage1 with DNA>2000 regardless of ALT or HbeAg
  • Extra-hepatic manifestations
  • Pregnant (24-32wk) if DNA >200,000 (to dec fetal transmission) - use Tenofovir and give baby HBIG + HBV vaccine
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36
Q

HepB Antiviral Treatment

A 
1st line: Nucleoside analogues (Tenofovir, entecavir, lamivudine)
Peg interferon (finite = 48w, ++side fx) - for low DNA, high ALT and noncirrhotic HbeAg+. NOT for decompensated cirrhotics
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37
Q

Hep B followup screening

A

Q6mo ALT + HBV DNA q6-12mo for all

US q6mo for HCC if: 
All Cirrhotics
Asian M>40, F>50
African American >20
HIV or Hep D Co-infection
FHX HCC (1st deg)

*NO AFP screening

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38
Q

HepB: Extra-hepatic manifestations

A

Rheum: PAN
Renal: membranous nephropathy > MPGN
Haem: aplastic anemia

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39
Q

Natural history HepB after acute infection

A

95% resolve spontaneously
5% develop chronic hep B
1% develop fulminant hepatic failure

40
Q

Natural history HepC after acute infection

A

33% resolve spontaneously

67% develop chronic infection

41
Q

Hepatits C: Who to screen

A 
All with cirrhosis
All Canadians born 1945-1975
Blood transfusion or transplant before 1992
Born in endemic area (africa, Asia, east europe, australia)
Current/past IVDU
Current/past incarceration
MSM
Household or sexual contact with HepC
HIV/HBV co-infection
Chronic dialysis patient
Increased ALT
42
Q

Extra-hepatic manifestations HepC

A

Renal: MPGN > Membranous
Autoimmune: Thyroid, myasthenia, Cryoglobulinemia, Sjogren’s, DM
Haem: ITP, AIHA, Lymphoma
Derm: Porphyria cutanea tarda, lichen planus, leukocytoclastic vasculitis

43
Q

HepC Treatment Indications

A

ALL except short life expectancy

44
Q

HepC Treatment Regimen

A

All based on direct antivirals, regimen deps on genotype, prognosis, co-infections and tx history

*Most: Sofosbuvir + (Ledipasvir or ribivarin) x 8-12 wks

2 Examples:

  • Maviret: Glecaprevir/Pebrentasvir
  • Epclusa: Sofosbuvir/Velpatasvir

Check viral load 12 weeks post treatment to confirm clearance (sustained virological response SVR12)

45
Q

EtOH Hepatitis Treatment

A

1) Prednisolone 40 OD if MADDREYS >=32 or MELD >20 for 7days; If Lille score on d7 >0.45 –> DC bc non-responder. If <0.45 (responder) continue x28 days then taper. Ensure no C/I eg infection (SBP, HBV, TB), GIB
2) EtOH Cessation
3) Refer to transplant if MELD >20 or CP-C
4) +/- NAC (for 30d survival in severe)
* No role for pentoxifylline except in HRS

46
Q

NAFLD Treatment

A 
Weight loss (dietary changes + exercise): 3-5% for steatosis, 7-10% improves fibrosis
Pioglitozone + VitE if Bx confirmed NASH (NOT NAFLD) 
Bariatric surgery (if obese)
Treat RFs: statins OK in compensated NAFLD/NASH cirrhosis, avoid in decompensation
47
Q

Causes of cirrhosis

A 
EtOH 
NAFLD
Viral Hepatitis (C>B)
AI (auto-immune hepatitis, IgG4 Dz, PSC, PBC)
Cardiogenic
Genetic: Hemochromatosis, Wilson's, A1AT
VTE
Idiopathic
48
Q

Work-up for new diagnosis cirrhosis

A

Hepatitis B/C serology
US with dopplers (r/o VTE)
Serum Igs
ANA, AMA, Anti-LKM, (+/- ASCA/ANCA if feats sugg)
Tsat/ferritin, ceruloplasmin, A1AT
+/- Biopsy if etiology not determined by above

Screen for complications:
- Varices (EGD at dx), Ascites/SBP (para at dx), encephalopathy, HRS, HCC (abdo US at dx)

49
Q

Child Pugh Score

A

ABCDE:
Albumin (>35=1, 28-35 = 2, <28 = 3)
Bilirubin (<34 = 1, 34-51 = 2, >51 = 3)
Coag: INR (<1.7=1, 1.7-2.2 = 2, >2.2 =3)
Distension/ascites (Absent=1, mild = 2, mod/sev =3)
Encephalopathy (Absent =1, grd1/2 = 2, grd 3/4=3)

CP-A = 5-6, CP-B=7-9, CP-C = >9 (Refer B and C for Transplant or if MELD15+)

50
Q

Treatment esophageal varices

A

If prior variceal bleed: EVL/Ligation + NSBB

If no past bleed (aka primary prevention):

  • If large/medium varices: EVL (q2-8w until obliterated) or NSBB (no rpt OGD needed)
  • If small w high risk feats (CP-C, whale or red spot) : Nadolol
  • If small without high risk feats: Observe, repeat OGD 1-2 yrs
  • If no varices: Rpt OGD q2-3 yrs for compensated, q1yr decomp
51
Q

Treatment ascites from portal HTN

A
  1. Salt restriction <2g/d (24h UNa <78 off diuretics = compliant)
  2. Diuretics (Spirono 100/ lasix 40) if refractory/noncompliant
  3. 24h uine Na on diuretics
    a) If losing weight + UNa >78 = CCM
    b) NOT losing weight + UNa>78 = noncompliant to Na restriction
    C) UNa<78 = increase diuretic dose until s/e
  4. Failing diuresis –> regular therapeutic para, TIPS (if no HCC or encephalopathy)
  5. Transplant
52
Q

Indications for SBP Prophylaxis

A
  1. Acutely during UGIB (can be without ascites)
  2. Past episode SBP (defined as ascitic PMN >250 or Cx+)
  3. Ascitic albumin <15 with either: a) Renal impairment (Cr >=106, BUN >=8.9, Na<130) or b) Sev liver impairment (CP-C, Bili >=51)
53
Q

Treatment SBP

A

1) Antibiotics: CTX 2g IV Q24hrs x5 days

2) Albumin: Day 1 = 1.5g/kg, Day 3 = 1 g/kg day if Cr >88, BUN >10.7, Bili>68

54
Q

Diagnosis Hepatorenal Syndrome

A

1) Progressive oliguric renal failure +
2) Benign urine sediment +
3) Urine protein <0.5 g/24 hrs +
4) UNa <20 +
5) Other causes AKI ruled out +
6) No improvement with discontinuation of diuretics and 2 day trial albumin 1g/kg

Type1 = AKI (2x Cr to >221 in 2 wks), 
Type2 = chronic renal failure with diuretic resistant ascites
55
Q

Treatment Hepatorenal Syndrome

A

Ward: terlipressin (risk resp failure) + alb > midodrine + octreotide + albumin
ICU: Norepinephrine + IV Albumin
Definitive Tx = Transplant

56
Q

Diagnosis Hepatopulmonary Syndrome

A

1) PaO2 <80, A-a gradient>=15 in pt with cirrhosis
2) Positive TTE Bubble study

Tx: O2 + liver transplant

57
Q

HCC Treatment

A

Curative: Surgery, Radiofreq ablation, Transplant
Palliative: TKI, chemo, rads, Transarterial chemoembolization (TACE)

58
Q

Hereditary Hemochromatosis: Screening and Diagnosis

A

Screening: Positive = Tsat >45% AND Ferritin >200 F/300 M (suspect organ dmg if ferritin>1000 –> MRI for HIC/fibroscan, bx if LE high)
Diagnosis: homozygous C282Y, hetero with H63D = less likely. Without C282Y = no risk

*screen all 1st deg relatives >18yo

59
Q

Hereditary Hemochromatosis: Treatment

A

Treat C282Y Homozygotes + complex heterozyg (C282Y/H63D)

a) Phlebotomy: Target Ferritin 50-100
b) Chelation if phlebotomy refractory (risk of retinal/auditory tox, agranulocytosis, liver/renal tox)
c) Avoid VitC, Fe containing supplements, raw seafood (vibrio, listeria, yersinia), normal red meat if phlebotomy
d) transplant if decompensated cirrhosis/focal HCC

*other heterozygotes = annual iron markers & asses organ dmg. No Tx

60
Q

Treatment PSC

A

ERCP Symptomatic strictures
MRCP q1yr r/o cholangioCA or GB Ca
Screen HCC/EoV if cirrhosis +/-transplant
NO Benefit of ursodeoxycholic acid

No curative Tx - progressive course

61
Q

Diagnosis PBC

A

2/3 of:

1) ALP > ULN x6+mo
2) AMA > 1:40
3) Liver biopsy

62
Q

Treatment PBC

A

Ursodeoxycholic acid (alters natural hx)
Management of cirrhosis if develops (only in 2/3)
Rarely need ERCP

63
Q

Diagnosis acute pancreatitis

A

2/3 of:

1) Consistent abdominal pain
2) Lipase or amylase >3x ULN
3) Characteristic imaging

64
Q

Treatment acute pancreatitis

  • general
  • gallstone
  • AI
  • TG
A

1) FLUIDS (250-500cc isotonic)
2) ANALGESIA
3) early enteral feeding (clear low at diet)
* If gallstone pancreatitis: ERCP (w/in 24 hrs if cholangitis/persistent obstruction/severe pancreatitis, otherwise >48h if non-resolving symptoms) AND Chole
* If AI Pancreatitis/IgG4 rltd: Steroid 40mg x4-6 wks then taper (steroids or aza or ritux if relapse)
* If TG pancreatitis: IV insulin, NPO +- PLEX, long-term fibrates

65
Q

Early pancreatitis complications (<4 weeks)

A

Interstitial edematous pancreatitis
Acute peri-pancreatic fluid collection
Pancreatic necrosis
Infected pancreatic necrosis/collection (if stable FNA –> cabapenem or quinolone+metronidozole, if unstable ABX –> Steroids)

66
Q

Late Pancreatitis Complications (>4 weeks)

A

Pseudocysts (endoscopic drainage if SS infxn)
Abscess
Walled off necrosis

67
Q

Chronic Diarrhea: Differentiating Cause

A

Stool Osmolar Gap = 290 - [2 x (StoolNa + Stool K)]
If <50-100 = Secretory –> Toxins, cholera/ETEC, VIPoma, gastrinoma, non-osmotic laxative abuse
If >100 = Osmotic or malabsorptive –> Celiac, chronic pancreatitis, lactose intol, lactulose or PEG misuse, post-whipple

C-scope if alarm features

68
Q

Microscopic Colitis Treatment

A

Budesonide PO, D/C NSAIDs, immodium

69
Q

Acute Cholangitis Features

A

Fever + RUQ Pain + Jaundice + Hypotension + Alt LOC

WBC>10 or <4, ALP/GGT >1.5xULN, ALT>1.5xULN, Bili>34

70
Q

Acute Cholangitis: Tx

A

1) ABX (CTX/flagyl, Cipro/Flagyl, Tazo, Carbapenem)

2) Source control (1st line = ERCP +/- sphincterotomy, 2nd = percut biliary drainage if ++comorbidities or failed ERCP

71
Q

Auto-antibodies in autoimmune hepatitis

A

ANA
ASMA
Anti-LKM
Anti-LC1

72
Q

Auto-antibodies in PBC

73
Q

Auto-antibodies in Crohn’s Disease

74
Q

Auto-antibodies in Ulcerative colitis

75
Q

Auto-antibodies in PSC

A

pANCA, ASCA, ANA

76
Q

Best test for acalculous cholecystitis

77
Q

Management of recurrent pleural effusions secondary to portal hypertension in cirrhosis

A

If requiring thoras more freq than q2-3 weeks + Age <70 + CP A or B –> TIPS
Otherwise, repeat thoras, Na restriction, diuretics

78
Q

Who to immunize for Hep A, including post-exposure ppx

A

-Travelers to Hep A Endemic countries, liver disease, MSM, IVDU, recurrent plasma derived clotting factors, zoo/vets handling primates
• Post-exposure ppx: household contacts, co-workers/ clients of infected food handlers, contacts in childcare or JK/SK

79
Q

Hep B factors increasing risk of cirrhosis/HCC

A

All of the below are for both, (HCC only)
- Host: older age, male, immunocompromised, coinfection with HIV/HCV/HDV, EtOH, metabolic syndrome, (aflatoxin ingestion, smoking)

Disease: High DNA/ALT, prolonged time to eAg seroconversion, eAg negative mutant, genotype C
-all of the disease factors also increase risk for HCC

80
Q

Hep C factors increasing risk of cirrhosis/HCC

A

Cirrhosis: older age, male, HIV/HBV coinfection, obesity/dm/fatty liver, EtOH

HCC: cirrhosis or coexisting liver dz

81
Q

Cirrhosis counseling

A
  • EtOH abstinence, NAFLD weight loss
  • Tylenol<2g/d
  • No sedatives, NSAIDs, ACE/ARBs
  • HAV/HBV/flu vaccines
82
Q

Ascites SAAG

serum ascites albumin gradient

A 
>11 = transudative (portal HTN)
<11 = exudative (Ca, pancreatitis, TB, nephrotic syndrome)
83
Q

Celiac RF’s

A 
Northern European
Family history - 1st deg
T1DM
AI Thyroid
Down/Turner
IgA def
84
Q

Postendoscopy Mx for nonvariceal UGIB

eg PPI duration, antiplatelets, anticoag

A

High risk ulcer: IV PPI BID or infusion x72h, then oral BID x2 weeks
Low risk: oral PPI

Restart antiplatelets, anticoag ASAP (timing dep on Forrest class and patient factors)
Assess RF:
-Test all PUD/gastritis for HPylori (EGD or serology), DC PPI after HP eradicated
-Indefinite PPI if ASA and/or Plavix for CAD
-Indefinite PPI if unclear PUD cause

85
Q

Who to test H Pylori

A
  • long term NSAIDs/ASA
  • PUD
  • unexplained Fe def,
  • MALT lymphoma
  • gastric Ca
  • ITP
86
Q

GERD Tx

A

Nonpharm: wt loss, avoid trigger food, no smoking, elevate HOB

Pharm: PPI OD 30-60min before meal x8 weeks (wean if improves), fail = ensure optimization and EGD off PPI

*NO prokinetics, sucralfate, baclofen, H2RA unless pregnant (sulcrate) or nocturnal acid reflux on monitoring pH (H2RA)

Surg for fundoplication, Roux en Y for eligible obese, or transesophageal incisionless fundoplication if declining classic lap fundo

87
Q

Barrett’s Presentation/RF

A

Metaplasia >1cm proximal to gastroesophageal jcn
Bx shows columnar intestinal metaplasia and goblet cells

RF:
Chronic GERD (>5y)
Fat white man >50yo that smokes
NOT affected by EtOH

88
Q

Achalasia complications

A

Megaesophagus >6cm
Sigmoid esophagus
Esophageal SCC&raquo_space;> adenoCa

89
Q

Eosinophilic esophagitis findings

A

Dysphagia+food bolus obstruction with >15 eos/hpf and no secondary causes

Endoscopy: trachealization (feline) esophagus, linear furrows, white papules, crate paper,

90
Q

Pancreatitis causes

A

Acute: Stones, EtOH, TG (>11mmol/L), hyperCa, drugs (GLP1, 5ASA, thiazides, azathioprine), AI, post ERCP, trauma, viral, Ca, hereditary, smoking, scorpion bites, vasculitis

Chronic: toxic (chronic EtOH, meds, toxins, smoking), metabolic (hyperCa, CF, hyper TG), idiopathic, AI, obstructive (pancreatic divisum, stricture, stone, tumor)

91
Q

LGIB DDX

A

Painless: diverticular, hemorrhoids, angiodysplasia, Ca, polyp, radiation proctitis

Painful: fissue, thrombosed hemorrhoids, ischemic colitis (crampy abdo pain w bloody BM) req workup (afib, LV thrombus, endocarditis, AAA< dissection, shock, low flow, segmental, vasculitis, PAN)

92
Q

Portal/Mesenteric Vein Thrombosis Workup

A
  • Thrombophilia + Jak2 testing if: 1) NO cirrhosis 2) Prior thrombosis 3) unusual thrombotic site eg hepatic veins 4) family hx
  • Imaging: US+ doppler
  • EGD to r/o esophageal/gastric varices
93
Q

Portal/Mesenteric Vein Thrombosis: who and how to Tx

A

No cirrhosis: Treat acute symptomatic or chronic w/ thrombophilia/ bowel ischemia/ clot progression into mesenteric veins
- IV UFH/LMWH –> warfarin/LMWH or offlabel DOAC x 6mo if acute trigger OR indefinite if thrombophilia -

If cirrhosis: treat as above, but also if awaiting liver transplant

94
Q

Ischemic colitis findings and tx

A

C-scope shows pale mucosa with petechiae or transmural infarction
Tx: broad spectrum abx + bowel rest + IVF +/- surg

95
Q

Esophageal Cancer risk factors

A

Squamous: Smoking, EtOH, Achalasia, Caustic injury, H&N cancer

Adeno: Barrett’s, Reflux

RCE (18 decks)

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