GI Case 1

Question 1

Factors that are protective against gallstones

Answer 1

• low carb diet
• physical activity
• Cardiorespiratory fitness
• Coffee (in women)
• High intake of Mg and polyunsaturated fats (in Men)
• high fiber diet and statin therapy
• ASA and NSAIDs

Question 2

Factors that are risk factors for gallstones

Answer 2

• Female
• increased age
• American Indians > mexican > nonhispanic whites > African Americans
• Obesity
• rapid wgt loss
• DM, glucose intolerance, insulin resistance
• high intake of carbs
• Hypertriglycerdemia
• M >M cirrhosis
• Prolonged fasting
• Pregnancy
• HRT/Oral contraceptives

Question 3

_ is defined as infection of biliary tract secondary to bile duct obstruction or bile stasis

Answer 3

Ascending cholangitis

Question 4

what lab changes are associated with ascending cholangitis

Answer 4

• hyperbilirubinemia
• leukocytosis
• transaminitis
• alk phos elevation

Question 5

what are the causes of ascending cholangitis

Answer 5

• choledolithiasis
• pancreatic/biliary neoplasm
• postoperative strictures
• choledocal cysts
• E.coli infection (most common of infectious cause); Klebsiella, enterobacter; enterococcus; bacteroides, clostridia

Question 6

What is chargot’s triad?

Answer 6

Signs of ascending cholangitis: Jaundice, fever (>102), and RUQ pain

Question 7

What is Reynold’s Pentad/

Answer 7

Signs of ascending cholangitis: Chargot’s Triad + mental status changes and hypotention

Question 8

How is ascneding Cholangitis treated?

Answer 8

• Urgent ERCP (12-24hrs); sphincterotomy and stone removal
• ABX
• Supportive care like IVF

Question 9

what are the first choice ABX for infectious cause of ascending cholangitis

Answer 9

Monotherapy: Amphicillin/sulbactam; piperacillin-tazobactam; ticarcillin–clavulate

Combo: 3rd gen cephalosproin PLUS metronidazole

Question 10

what labs should be followed in someone with ascending cholangitis

Answer 10

• AST/ALT, Alk phos, fractionated bili, amylase/lipase
• pre procedure INR
• FU on blood cultures and bile cultures

Question 11

complications of post ERCP

Answer 11

• pancreatitis
• ascending cholangitis
• less commonly: hemobilia, perforation, bile leaks

Question 12

What is mirizzi syndrome?

Answer 12

• common hepatic duct obstruction caused by extrinsic compression from an impacted stone in cystic duct
• cholecystoenteric fistula can occur

Question 13

what AEs are associated with TNF-a inhibitors?

Answer 13

Used for RA and IBD. AE includes: infection (pneumonia, TB, opportunistic etc); injection site rxn; cutaneous reactions (psoriasis, eczema, SLE, Lichen planus),; malignancy; induction of autoimmunity (autoimmune hepatitis, SLE, psoriatic skin lesion, inflammatory eye disease, interstitial lung disease, MS, sarcoidosis, dermatomyositis

Question 14

What is diaphragmatic excursion

Answer 14

Determine the distance between level of dullness on full expiration and level of dullness on full inspiration by progressive percussion down from resonance (lung parenchyma) to dullness (structures below diaphragm.
normal is 3-5.5 cm

Question 15

what is branchophony?

Answer 15

when spoken words become louder and clearer. Indicates consolidation, effusion, mass etc

Question 16

What is egophony?

Answer 16

patient says ee and sounds like A. (normally sounds muffled long E sound). Indicates consolidation, effusion etc)

Question 17

what is whispered pectoriloquy?

Answer 17

whispers are heard louder and clearer during auscultation

Question 18

what is grey turner sign

Answer 18

Flank ecchymosis secondary to hemorrhage

Question 19

What is cullen sign

Answer 19

ecchymosis around the umbilicus (periumbilical) secondary to hemorrhage

Question 20

what is Rovsing’s sign

Answer 20

Pain in RLQ during left-sided pressure-referred rebound tenderness seen in appendicitis

Question 21

McBurney’s Point

Answer 21

rebound tenderness or pain 1/3 of the distance from ASIS to umbilicus (appendicitis/peritoneal irriation)

Question 22

What is murphys sign

Answer 22

palpate deeply under right ostal margin during inspiration, and observe for pain and/or sudden stop in inspiratory effort. Tests for acute cholecystitis or cholelithiasis

Question 23

what is Courvoisier’s sign

Answer 23

Enlarged non-tender gallbladder secondary to pancreatic disease or cancer

Question 24

For each of the organ indicate the sympathetic levels involved:
A. Esophagus
B. Stomach
C. Liver
D. Gallbladder 
E. small intestine
F. Colon
G. Pancreas
H. Appendix

Answer 24

A. T2-T8
B. T5-T9
C. T6-T9
D. T6-T9
E. T9-T11
F. T10-T12
G. T5-T11
H. T12

Question 25

What is Iliopsoas muscle test testing for?

Answer 25

Irritation of psoas muscle from inflammation of the appendix. have pt flex hip against resistance, pain is positive test

Question 26

What is Obturator muscle test

Answer 26

Flex pts right thigh at hip, with knee bent and rotate leg internally at hip. Right hypogastric pain is positive test = irritation of obturator muscle from inflamed appendix

Question 27

when do you suspect choledocholithiasis on US

Answer 27

when common bile duct is >6mm. Normal is 3-6. Elderly or post cholecystectomy can be 10 mm.

Question 28

what do you have to consider when giving a biliary patient opioids?

Answer 28

• NSAIDs are preferred but opioids can be give if NSAIDs are contraindicated.
• Opioids increases sphincter of Oddi pressure –> more pain
• opioids slows diestive tract –> possible ileus, constipation