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Clin Med > GI Exam > Flashcards

GI Exam Flashcards

1
Q

What’s the recommended repair for umbilical hernias <2cm?

A

simple suture, +/- mesh

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2
Q

Extrasphincteric is Parks __ and is located…

A

4

High anal canal to buttock’s skin

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3
Q

The big three s/s for cholangitis are ___, __, and ___. That’s called…

A

CHARCOT’S TRIAD: fever + jaundice + severe RUQ pain

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4
Q

Which GIB is more common?

A

Upper (1/1000 people a year)

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5
Q

A pt’s U/A comes back positive for albuminuria. Which liver enzyme, if it had also been present in that urine sample, would make you suspect renal disease?

A

Unconjugated bili, which is bound to albumin, and would ONLY be in urine if pt had renal disease.

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6
Q

What happens if you don’t drain your pt’s abscess?

A

–> Sepsis!

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7
Q

Your pt has one immediate family member who was Dx’d with CRCa at age 45. Is the pt high risk? What should we do screening-wise?

A

Yes they are risky! 45yo is young AF to get CRCa.

Start doing colonoscopy q5yr at age 40, or maybe even age 35 since that’s 10yrs younger than when his fam jam was Dx’d.

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8
Q

One of the biggest risk factors for Crohn’s is __. Another is a PMHx of __ infection.

A

FamHx!!

Gastroenteritis infection

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9
Q

CBC of GIB initially is normal. Why? When do you repeat?

A

Catecholamines. Repeat q2-8hr

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10
Q

What is the only type of neoplastic polyp we discussed?

A

Adenomatous!

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11
Q

General PE findings that suggest GIB?

A

HEENT - pale conjunctiva, pale/dry oral mucosa
SKIN - cold and clammy
CARDIAC - Resting tachy/POTS
ABD - starts normal, becomes caput medusa/ascites/rebound tenderness
RECTAL - +guaiac

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12
Q

What are the extraintestinal Sx of celiac?

A 
FASHON
Fe-def anemia
Abd protuberance
Skin stuff
Hormonal stuff
Osteoporosis
Neuro stuff
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13
Q

A Grade I internal hemorrhoid looks like…

A

A non-prolapsed bulge only visible on anoscopy

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14
Q

When would we use monoclonal antibodies in CRCa Tx?

A

Stage IV as an add-on to traditional chemo

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15
Q

Give me the quick-and-dirty lowdown on irinotecan.

A

Use it as part of triple chemotherapy.

Topo1i.

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16
Q

Why do UGIBs occur? (4ish)

A 
PUD (GASTRIC > duodenal)!
Esophageal varices
Erosive Esophagitis/gastritis
CA/polyps
etc.
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17
Q

Half of all CRCa’s happen in what part of the colon? For which popn is that NOT the case?

A

Rectosigmoid

Except African-Americans - theirs is more often proximal colon.

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18
Q

What’s the difference between incarceration and strangulation? How do you Tx them?

A

Strangulation is when incarceration gets necrotic. Both are surg emerg!!!

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19
Q

What three lab values are very elevated in choledocholethiasis? What other one might rise?

A

AST and ALT will be >1000
Total bili will be high
Alk phos will rise slowly

Amylase +/- elevated

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20
Q

5ish Causes of LGIB?

A

LGIB - DIVAS

DIVERTICULOSIS BLEED
Inflammatory conditions (IBD, CA)
Vascular ischemia
Anorectal stuff (fissures etc)
S/p surg
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21
Q

What is a pillow sign and what does it suggest?

A

When you leave behind an indentation from forceps

= Lipoma (most common submucosal)

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22
Q

How do we Tx advanced (Stage IV) anal CA?

A

Palliative systemic chemorad :/

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23
Q

The colon is in the __ and the rectum is in the __, meaning that rectal CA is harder to surg and needs __ before doing it.

A

Abd cavity

Peritoneal space - need neoadjuvant Tx pre-op

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24
Q

If painful BM is occurring with fever, night sweats, and weight loss, think…

A

Colon CA!

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25
Q

A Grade IV internal hemorrhoid looks like…

A

Prolapsed, irreducible, may strangulate

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26
Q

HxPE can pretty much nail an anal fistula Dx, so why might I order imaging?

A

For complex ones, esp. if my pt has Crohn’s.

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27
Q

Which IBD is friable? Which one has erosions?

A

UC for both.

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28
Q

When staging CRCa, how many lymph nodes do you need to dissect?

A

12+!

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29
Q

What abx would we give to Tx pilonidal disease, if that’s determined to be needed?

A

Cefaz + Flagyl

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30
Q

What is CEA and what would we use it for with regards to CRCa?

A

Carcinoembryonic antigen - get pre and post-op to monitor recurrence

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31
Q

What is a more liver-specific enzyme than alk phos?
If alk phos is elevated but GGT isn’t, think ____ problem.
If both alk phos and GGT are elevated, think ____.

A

GGT
+ Alk phos/ - GGT = Bone issue.
+ Alk phos/ + GGT = Liver issue.

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32
Q

We LOVE colonoscopies. What are the few risks of it?

A

Anesthesia issues
Perf/significant bleeding
Old pts - dehydration/electrolyte issues

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33
Q

What will ECG of GIB show?

A

Nonspecific, isoelectric or flipped T waves

and r/o CAD etc

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34
Q

Name the 5ish more strongly associated extraintestinal manifestations of UC.

A 
APPLE
Ankylosing spondylitis
Pyoderma gangrenosum/mouth ulcers
PSC
Lots of joint pain
Erythema nodosum
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35
Q

If you found >10 adenomas on a scope, when should your next f/u scope be?

A

3 yrs later or less!

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36
Q

What’s the difference between Kwashiorkor and Marasmus?

A

Kwashiorkor - adequate kcal, inadequate protein (more developing countries)
Marasmus - inadequate protein AND kcal (more emaciated)

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37
Q

Give me the quick-and-dirty lowdown on capecitabine.

A

Breaks down into 5-FU; can use instead of 5-FU+leucovorin.

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38
Q

Treat an external hemorrhoid with __, __, __, and maybe ___ drugs.

A

Hydrocortisone cream or suppository
Witch Hazel
Zn2+ oxide
+/- anesthetic

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39
Q

ADMIT Crohn’s pts with:

A

Bowel obstruction
Abscess
Serious infection
Severe Sx!

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40
Q

Describe the unique pain of cholelithiasis.

A

Sudden-onset, intermittent epigastric or RUQ pain that may radiate to shoulder, accompanied by N&V.

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41
Q

What’s the name of the protocol we use to stage severity of UC?

A

Montreal Classification (E1 is best, S3 is worst)

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42
Q

A pt’s U/A comes back positive for albuminuria and conjugated bilirubinuria. What do they have?

A

Direct hyperbilirubinemia

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43
Q

How do you Dx lactose intolerance?

A

50mg lactose po, then Hydrogen Breath Test (+ if rise of 20+ppm in 90min)

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44
Q

What are the three classifications of abscesses? Where is each located?

A

Ischiorectal (aka ischioanal): within buttock, obvious red/diffuse ext findings
Intrasphincteric: between int and ext sphincters (+/- ext findings)
Supralevator: above levator (no ext findings)

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45
Q

What is the most common type of non-neoplastic polyp and what do they look like?

A

Hyperplastic (serrated, kind of look adenomatous, but usually <5mm by rectosigmoid)

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46
Q

Progression of Crohn’s Tx, from mild to severe?

A

5-ASA and supportive (loperamide, BAS) –> short-course Budesonide –> MTX or azathioprine –> TNF-a blockers –> anti-integrin (Vedolizumab)

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47
Q

Your pt has two family members who were Dx’d with CRCa, but they’re not immediate family. Is the pt high risk? What should we do screening-wise?

A

Not risky, screen just like any random healthy dude

But when you do get around to screening, use colonoscopy.

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48
Q

Don’t bother screening anyone over __yo for CRCa.

A

85yo (over 75yo, use your discretion)

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49
Q

On your pt’s coag panel, you see that their PT is high. What does that mean, and what three reasons that could happen?

A

Longer bleeding time/harder to clot
VitK-def
Cholestasis
Hepatitis

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50
Q

Name the three types of submucosal polyps. Are they neoplastic?

A

Lymphoid
Fibroma
Lipoma

NO

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51
Q

What anatomic structure determines whether a hemorrhoid is internal or external?

A 
The dentate (pectinate) line
(they can also be mixed)
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52
Q

4 main Sx of Crohn’s?

A

Intermittent!: lo-fever + watery diarrhea + RLQ pain + perianal stuff

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53
Q

If a FamHx makes FAP suspicious, how should we screen and when?

A

Starting at 10-12yo - flex sig
Genetic test
Then colonoscopy qyr once +polyps

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54
Q

How do we Dx anal cancer? (3)

A

Anoscopy
Rigid proctosig
Endoscopy + Bx

(ARE you going to Dx ass cancer today?)

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55
Q

Dx study of choice for suspected cholecystitis? What’s another (more pricey) choice, and what does a ‘positive’ look like?

A

U/S

HIDA: + = tracer dye doesn’t enter gallbladder.

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56
Q

What is Wernicke-Korsakoff Syndrome?

A

Severe CNS involvement from thiamine-def.

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57
Q

~~~the gold standard for CRCa Dx is …. ~~~

A

Colonoscopy!

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58
Q

What is Boerhaave Syndrome?

A

B is for Bad!!!
Spontaneous esophageal rupture, usually after forceful emesis.
Transmural.

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59
Q

How do you diagnose a hemorrhoid?

A

PE + DRE + Anoscopy (all 3!)

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60
Q

What is a hemorrhoid?

A

A NORMAL AV tissue poop cushion.

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61
Q

Why is it called Familial ‘Juvenile’ Polyposis? Where does it present?

A

Histologically, the polyps are ‘young’ not advanced.

Throughout GI tract (sm int on)

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62
Q

Surg in Crohn’s pts is normally a bad idea because of the super-high rate of recurrence. What are some situations in which it’s worth it?

A 
CA
Fistulas that just won't quit
Abscesses
Perf
Toxic megacolon
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63
Q

Anal CA below the dentate line is aka ___.

A

Keratinizing SCC (think about it - keratin is skin/nails, so more external than internal)

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64
Q

What fatty acid is essential (dietary)?

A

Linoleic acid

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65
Q

What is Turcot Syndrome and what does it have to do with GI…?

A

Brain malignancy + GI hereditary disorder.
Ex: gliomas + Lynch Syndrome
Rare ex: medulloblastoma + FAP

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66
Q

The first enzyme to get elevated in liver damage is usually __.

A

GGT

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67
Q

UGIB Tx (fyi)

A

Central line, T&C, IVF/blood/clotting factors
Intubate if massive bleeding
IV PPi bid, IV octreotide
GI consult will do Endoscopy if HD stable!, TIPS if varices rupture

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68
Q

Tx protein-caloric malnourishment by…

A

Calling a nutrition consult.

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69
Q

What all is the colon responsible for absorbing? Excreting?

A

VitK, salt, water

Excrete: potassium

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70
Q

1,25-dihydroxyvitD does __ and __.

A

Absorption of dietary Ca2+

Stimulating osteoclasts

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71
Q

3 stages of Fe-def?

A

Depletion of iron without anemia
Anemia with normal MCV
Microcytic, low-ret anemia.

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72
Q

__ and ___-def cause macrocytic anemia.

A

Folate-def and B12-def!

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73
Q

How often should a UC pt with PSC get a colonoscopy? Why?

A

qyr!

Cholangiocarginoma risk

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74
Q

B12-def is most common in __, ___, and ___.

A

Vegans, EtOHics, s/p gastric/ileal surg pts!!!

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75
Q

VitD-def is the most common cause of…

A

Osteomalacia

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76
Q

How often should your CRCa pt get a f/u physical exam post-op?

A

q3-6mo x 2yr
then
q6mo x 3yr

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77
Q

Thiamine-def is usually d/t…

What is a common co-deficiency?

A

Chronic EtOHism

Folate-def

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78
Q

Suppurative cholangitis: pus comes out of…

A

the ampulla of Vater

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79
Q

What’s my horrible way to remember the special characteristics of Crohn’s?

A 
Crohn is a fatass.
Fistulas
Abscesses
Transmural
Adhesions
Sinus tracts
Strictures
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80
Q

Inherited polyposis syndromes are __ __ pattern.

A

Autosomal dominant

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81
Q

Where do femoral hernias protrude?

A

@ femoral ring… duh.

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82
Q

Sx of hemorrhoids?

A

ASx!

Or, BRBPR painlessly with BM

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83
Q

3 things to look for on the physical exam of a suspected anal CA pt?

A

Bleeding + Condylomata + Mass on DRE

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84
Q

What’s the difference between a perianal abscess and a perianal fistula? What’s important to note about abscesses?

A

Abscess = acute
Fistula = chronic
Drain abscesses promptly!

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85
Q

Give me the quick-and-dirty lowdown on leucovorine.

A

Use as a co-px for 5-FU to make them bind better.

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86
Q

Most hereditary polyposis syndromes have what type of polyp? What does it look like? Are they neoplastic?

A

Hamartamous (disorganized)

No, but they CAN lead to CRCa if they get dysplasia’d

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87
Q 
A cholestatic pattern on labs puts these five disease processes on your DDx:
Primary \_\_\_\_\_
Primary \_\_\_\_\_
\_\_\_\_\_ CA
\_\_\_\_\_carcinoma
\_\_\_\_\_\_.
A
  • Primary biliary cirrhosis
  • Primary sclerosing cholangitis
    Pancreatic CA (don’t fuck with the pancreas. Evil spirits)
    Cholangiocarcinoma
    Choledocholithiasis
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88
Q

Charcot’s triad + ___ + ___ = a major endoscopic emerg. Together, these s/s are known as…

A

Hypotn + Altered mental status

Reynold’s Pentad

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89
Q

Goodsall’s Rule deals with fistulas within _cm of the anal verge.
Posterior to the ‘transverse anal line’ (between the ischial spines), what way do fistulas go?
What about anterior to the transverse anal line?

A

3cm
Curvilinearly to posterior midline
Radially (straight line)

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90
Q

More intense hemorrhoids can be treated by…

A

Doppler-guided hemorrhoidectomy

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91
Q

How do we Dx pilonidal disease? What’s the most common Tx of it?

A

HxPE

I&D under local anesthesia, packed c gauze

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92
Q

If an external hemorrhoid has a clot and it’s been under 72hr, treat it by…

A

Wide excision + evacuation

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93
Q

Your pt has Stage IV CRCa and you are ready to add-on a monoclonal antibody. Why might you specifically pick Bev- for them?

A

If they are KRAS+.

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94
Q

Non-negotiable, all Crohn’s pts should…

A

quit smoking!!!!

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95
Q

Who gets pilonidal disease?

A

Men > women (but both do) around 20yo, esp if overweight

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96
Q

Your pt has Crohn’s. What do you want to know before you give screening advice? What IS your screening advice?

A

How long it’s been since they started getting colitis Sx.

8+yrs since that? Colonscopy q1-2yr.

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97
Q

In cholecystitis, there will be leukocytosis. Fo’ sho. What other four lab values could be elevated?

A

Alk phos
AST/ALT
Total bili
Amylase

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98
Q

What makes up bile?

A

Bile acids + cholesterol + phospholipids

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99
Q

Reeeeally low albumin in a blood sample suggests __, __, or ___.

A

Malnutrition
Cirrhosis
Severe hepatitis

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100
Q

What are the three options (and their timeline) for CRCa screening preventatively?

A

Colonoscopy q10yr
Flex sig q5yr (or q10 if + FIT)
CT colonography q5yr

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101
Q

Alk phos is found in ___, is elevated when ___, and normal value is _____.

A

Liver and biliary tract, bone, and a few other places.
Obstructions/stones/tumors
45-114 U/L

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102
Q

Who is most likely to get abscesses and fistulas?

A

Men around 40 yo!

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103
Q

Why are desmoid tumors bad?

A

FAP pts die from its mets.

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104
Q

Your 20yo pt has HNPCC. What is that also known as again…? Obviously they need monitoring via colonoscopy, but how often?

A

Lynch Syndrome
q1-2yrs, definitely qyr once they hit 40yo.

(age 20 is a good time to start, or 10yr younger than when their other relatives with Lynch got polyps.)

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105
Q

RDAs have been replaced by __.

A

DRIs

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106
Q

Crohn’s often presents very similarly to what other GI issue?

A

SBO

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107
Q

Big 3 Sx of UC?

A 
Bloody diarrhea (<4 is mild, >6 is severe)
Abd pain (LLQ usually)
Rectal bleeding
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108
Q

Hernias generally can be __ (like __ or __), or __ (like __ or __).

A

Groin - inguinal, femoral

Ventral - incisional, umbilical

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109
Q

Perianal/anal margin CA occurs where?

A

In the skin, or just outside the squamous mucosa.

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110
Q

You get a pt’s labs back, and their alk phos is normal, AST and ALT elevated, and total bilirubin is elevated. What pattern do you see? What do you suspect?

A

Hepatocellular

Intrahepatic injury

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111
Q

What’s a distinguishing feature of PJS? What do its polyps look like?

A

Dark discolorations on skin and mucous membranes

Hamartamous

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112
Q

A Grade III internal hemorrhoid looks like…

A

A bulge that prolapses with straining but requires manual reduction after

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113
Q

LGIB Tx (fyi)

A

Central line, T&C, IVF/blood/clotting factors

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114
Q

What is hydrops of the gallbladder?

A

Mucocele that forms in the gallbladder, potential complication of gallbladder surg

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115
Q

4 possible imaging studies for choledocholethiasis? Which is the most advantageous?

A

RUQ U/S
CT
MRCP
ERCP (good because you can add stent while there to Tx)

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116
Q

What is a direct inguinal hernia?

A

Protrudes @ Hesselbach’s triangle (medial to int epigastric vessels)

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117
Q

If any pt over 40yo presents with hematochezia and bowel changes…

A

R/O CRCa!!! (scope ‘em!)

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118
Q

People with FAP GET CA. Usually around age __. What are some extracolonic CA they might also get (7)?

A

40yo.
Pancreatic, thyroid, gastric (fundic gland), sm int (duodenal adenoma); desmoid tumor (conn tiss), CHRPE, or Turcot (rare).

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119
Q

FAP is a mutation in the __ gene that starts presenting with __ at __ yo.

A

APC
>100 adenomatous polyps
~16yo

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120
Q

What is the most common tip-off to Lynch Syndrome?

A

PMHx/FamHx of extracolonic malignancies!!! Esp endometrial carcinoma!

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121
Q

What in the heck is choledocholethiasis?

A

A stone in the common bile duct

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122
Q

FAP pts get fundic gland polyps. What’s important to know about them?

A

Non-neoplastic!

Hard to remove.

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123
Q

How do we treat Grade II-III internal hemorrhoids?

A

Rubber band ligation

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124
Q

Your Crohn’s pt gets an SBO. How do you Tx it?

A

IV steroids + NG tube decompression

surg if that fails

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125
Q

What’s the order of Tx for UC, mild –> severe?

A

5-ASA –> Budesonide (or prednisone) –> hospitalize and IV steroids –> monoclonal antibodies –> cyclosporine –> surg.

Surg is the only actual cure.

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126
Q

We’re not really sure about the pathophys of IBD, but generally throw out three keywords.

A

TLRs
Autoimmunity
Junction damage

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127
Q

What is the most common surg used to take out rectal CA?

A

Transanal excision

runner-up: total mesorectal excision

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128
Q

New-onset anemia is ___ til proven otherwise!

A

A bleed!

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129
Q

Your pt had CRCa, but had the cancer part yanked out. Does he still need colonoscopy screening?

A

Yes! Do your first colonoscopy within a year of the surg, and then 3yrs after.
All good then? Repeat q5yr.

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130
Q

The most common hereditary colon CA is ___ aka ____.

A

Lynch Syndrome aka Hereditary Nonpolyposis CRCa

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131
Q

What do thrombosed external hemorrhoids look like?

A

Purplish-blue and acutely tender

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132
Q

Okay, let’s be a little more specific. What kind of surg do we use to take out colon CA?

A

Lap or open, total or subtotal, +/- ostomy

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133
Q

CMP shows BUN:Cr ratio 20:1. Why?

A

Pre-renal state; digested blood proteins getting absorbed into circulation

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134
Q

For celiac labs, you’d want to get __ for the vit-def stuff, __ for the malnutrition stuff, __ because of the low VitK, __ because of the fat malabsorption, and __ to check for co-occurring lactose intolerance.

A 
CBC
CMP
INR/coag
Fecal stool
Oral tolerance tests
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135
Q

What are the three general procedure choices for anal fistulas?

A

Fistulotomy + fibrin sealant
Fistulotomy + setons
Anal advancement flap +/- fibrin seal

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136
Q

What extracolonic malignancies are most common in PJS pts? What monitoring do they need because of that?

A

Breast and testicular

So exam qyr + mammogram/breast U/S!

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137
Q

LGIB blood loss originates ___

A

In colon, distal to Ligament of Treitz

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138
Q

ALT is found in ___, is elevated when ___, and normal value is _____.

A

Hepatocytes
Hepatocyte damage
7-55 U/L (varies by pt popn)

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139
Q

Who gets ass cancer and why?

A

Women more often, or anyone active in anal sex, d/t HPV

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140
Q

What is Mallory-Weiss Syndrome? What similarity does it have with Boerhaave Syndrome?

A

Nontransmural esophageal tear

Also with vomiting

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141
Q

Hey, what’re some great ways your pt can help keep themselves from getting CRCa?

A

Stop smokin, drinkin, and givin yourself diabetes!

also ASA qd…?

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142
Q

Where are four common locations for CRCa to metastasize to?

A

Peritoneum
Liver
Lungs
Lymph nodes

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143
Q

General Sx of UGIB? Think through effects of blood loss, then think through possible causes.

A

BLOOD LOSS = POTS, Confusion, CHEST PAIN (suspect if PUD Hx, nonspecific T-wave flattening), Cold/clammy extremities

PUD = epigastric/RUQ pain

Ulcer = GERD, odyno/dysphagia

Mallory-Weiss tear = cough then hematemesis

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144
Q

FAP pts get duodenal adenomas. Where in the duodenum do they happen?

A

Papilla of Vater

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145
Q

Celiac is aka __. What is it? What does it affect?

A

Gluten enteropathy - an immune rxn to gluten catabolite

Affects proximal small bowel

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146
Q

How to Tx LGIB?

A

It usually self-resolves

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147
Q 
A hepatocellular pattern on labs is a little less easy - here's some things that you can consider on your DDx:
Hepatitis, \_\_ or \_\_\_
EtOHic
Drugs/toxins
\_\_\_ disease
Ischemia, like d/t \_\_\_ or \_\_\_.
A

Viral or autoimmune
Wilson’s
Budd-Chiari, ischemic hepatopathy

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148
Q

Besides the usual anal crypt gland infection, an infection where can cause a supralevator abscess?

What would a pt with a supralevator abscess present with complaints of?

A

From a pelvic infection

SEVERE perianal pain, fever. +/- urinary retention

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149
Q

The most important lab when evaluating protein malnutrition is __. What are the two syndromes with lowered values of that?

A

Albumin

Kwashiorkor and Marasmus

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150
Q

How does chronic pilonidal disease present?

A

Recurrent persistent pain
Drainage
Tender/red mass

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151
Q

LDH is found in ___, is elevated ___, and normal value is _____.

A

Liver and blood
Anytime there is tissue damage
140-280 U/L (fyi)

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152
Q

Normal B12 value is __.

Peripheral smear looks like…

A

210 pg/mL

Megaloblastic with hypersegmented neutros!!

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153
Q

How do you Dx each type of abscess?

A

Ischiorectal - visible on PE
Intrasphincteric - DRE
Supralevator - Hx, maybe DRE, usually need CT

Could also use transperitoneal or endorectal U/S

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154
Q

You Dx your pt with acute cholecystitis and decide they need a lap chole. Good choice. What do you do in the meantime, though? (3)

A
  • Make them NPO & start IVF
  • Prescribe a non-morphine pain Rx (since morphine –> Sphincter of Oddi spasm)
  • Start IV Flagyl + 3rd-gen CPN
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155
Q

Gastric vs duodenal ulcers

A

Gnawing/burning pain is shortly after meals for gastric, 2-3hr later for duodenal.
Gastric is more common in PUD.

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156
Q

Where does pilonidal disease occur?

A

Butt crack!!
(jk jk it’s the ~intergluteal cleft~/upper natal cleft)
Both skin and SQ

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157
Q

Most important thing to be able to do in GI bleeds?

A

Find the bleed, stop the bleed.

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158
Q

What type of groin hernia is most common, and who gets it most often?

A

Indirect inguinal hernia

50-70yo white men > 60-80yo white women (but both get it)

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159
Q

When would UC be considered emergent? What do we do about it?

A

Fulminant UC/Toxic Megacolon

Colectomy stat!

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160
Q

Give me the quick-and-dirty lowdown on oxaliplatin.

A

Must use as a 5-FU add-on, not alone

ADR: periph neuropathy

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161
Q

Dx study of choice for suspected cholelithiasis? What’s another (more pricey) choice?

A

U/S

HIDA

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162
Q

What four things do I need to get before cutting the CRCa out of my pt?

A

Labs: CBC c diff, LFTs, CEA level

To stage: chest/abd/pelvic CT

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163
Q

Sx of VitB12-def are __ of tongue, __ neurologically, and ___ anemia. (similar to folate-def)

A

Glossitis
Paresthesia/dementia/balance issues
Slow-onset

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164
Q

Name 5 other procedures (besides I&D) to Tx pilonidal disease.

A 
Excision
Primary closure
Off-midline closure
Z-plasty
V-Y advancement flap
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165
Q

Pre-op, what is good to order on a RECTAL cancer pt?

A

Endorectal U/S

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166
Q

Inherited polyposis syndromes are really rare, so in what four circumstances would I even consider it?

A

1) >1 FamHx CRCa.
2) PMHx or FamHx CRCa Dx’d <50yo.
3) PMHx or FamHx >#20 polyps.
4) PMHx of FamHx multiple extracolonic malignancies.

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167
Q

How does an anal fistula present (3ish)?

A

Intermittent rectal pain that worsens c BM/sitting/movement
Drainage that smells horrid
Visible inflam/palpable cord

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168
Q

Folic acid lower than __ is a deficiency. What else should you check at the same time and why?

A

150 ng/mL

Check B12 too! Fixing folic acid-def will mask a B12-def.

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169
Q

Your pt has two family members who were Dx’d with CRCa, and they are immediate family, but over 60yo. Is the pt high risk? What should we do screening-wise?

A

Yes they are risky! Two immediate fam is a lot.

Start doing colonoscopy q5yr at age 40, or 10yrs younger than their fam’s Dx age.

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170
Q

What’s more important to note than BMI?

A

Unintentional wt loss of 10% or more

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171
Q

Unfortunately, doing too many resections or having too many fistulas-and-stuff leads to __ in Crohn’s pts.

A

Malabsorption syndromes.

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172
Q

What is pernicious anemia?

A

Autoantibodies against B12 and IF

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173
Q

Marasmus-like deficiency occurs in diseases like… (4)

A

HF, COPD, CA, AIDS

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174
Q

What are the 3 most common presenting Sx for RECTAL CA?

A

Hematochezia + narrowed stool + tenesmus

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175
Q

Which types of abscesses need to be drained in the OR? How?

A

Perirectal - intersphincteric, or supralevator stemming from pelvic infection

Through the rectum :0

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176
Q

Besides an elevated alk phos, what else helps me Dx cholestasis?

A

U/S to check for blockages as cause

CT or MRI to check for liver damage as cause

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177
Q

Normal total bili is ___.

Normal direct bili is ___.

A

0.3-1.9 mg/dL

0-0.3 mg/dL

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178
Q

You get a pt’s labs back, and their AST and ALT are very elevated, their alk phos is mildly elevated, and total bilirubin is normal. What pattern do you see? What do you suspect?

A

Hepatocellular pattern
Intrahepatic injury
(total bili does NOT have to be elevated for it to be hepatic!)

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179
Q

What are the three types of adenomatous polyps, listed from least to most scary? Which is most common?

A

Tubular (most common)
Tubulovillous
Villous

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180
Q

Half of all Crohn’s pts have involvement in …

A

Terminal ileum + ascending colon

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181
Q

Which type of hemorrhoids are viscerally innervated? As a result, what are their characteristics?

A

Internal

NTTP/pain/temp

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182
Q

Age and race of UC pts? What infections are associated with triggering UC?

A 
15-30 and 50-70yo Ashkenazi Jews
GI infections (campylobacter, shigella, salmonella)
183
Q

Keep an eye out for _ + _ + _ which should scream “metastatic CRCa!!!!!”

A

Wt loss + ascites + cachexia !!

CRaCk is WACk

184
Q

What does a sphincterectomy remove? What is the main complication?

A

Lateral internal sphincter

Can cause fecal incontinence

185
Q

Why put in an NGT tube in a GIB pt?

A

To see if there is active UGIB, differentiate it from LGIB. Controversial

186
Q

It’s the usual CA workup for a confirmed anal CA Dx, aka __, __, +/- __.

A

CT/MRI (Abd/pelv)
PET-CT
FNA

187
Q

What population is especially prone to cholelithiasis?

A

Native Americans, and Fat Fertile Forty Fair women.

188
Q

How and in whom do we Tx cholelithiasis?

A

Sx pts who are smart: lap chole
Sx pts who refuse surg: 2yrs of Chenodeoxycholic and Ursodeoxycholic Acid and by the way stones very well may come back ?? lame

189
Q

General Sx of LGIB? (3ish)

A

Blood - melena/hematochezia/BRBPR
PAINLESS BLEEDING
+/- abd pain/fullness

190
Q

Your pt definitely has FAP and now they get a colonoscopy qyr because you found polyps. What else should you start doing to monitor/Tx them (4)?

A

EGD q1-3yr once 20yo +
Chemoppx COX2i 400mg bid +
Ppx Colectomy +
Screen what’s left q6mo-2yr

191
Q

If a Crohn’s pt is gonna get an extraintestinal manifestation, what 3ish things is it most likely to be?

A

Uveitis
Arthralgia
Pyoderma gangrenosum or erythema nodosum

192
Q

Which types of abscesses can be drained outpt? How?

A

Perianal - ischiorectal, or supralevators that extend from ischiorectal.

I&D

193
Q

_-sided CRCa is more common in inherited CRCa. _-sided CRCa is more common in nonhereditary CRCa. Which is more common?

A

Right - inherited

Left - sporadic (75% of CRCa, so way more common)

194
Q

What are the four chemo Rxs preferred for CRCa? (note - can do combos, they all have weird names like ~fox~ and ~ox~)

A

5-FU
Oxaliplatin
Irinotecan
Leucovorin

195
Q

What is the ‘best’ type of polyp? What do they look like?

A

Mucosal (<5mm, look like surrounding tissue)

196
Q

High-risk PMHx for CRCa includes 1) having a polyposis syndrome, 2) having IBD for more than __ yrs, 3) having ___, 4) having __, and 5) being __.

A

8yrs
Previous CRCa (duh)
Large (>1cm) or icky (tubulovillous/villous) adenoma
black

197
Q

Transphincteric is Parks __ and is located…

A

2

Through ext sphincter to ischiorectal fossa

198
Q

More gallstones are made of ___ than __. What is the precursor to actual stones?

A

Cholesterol > calcium bilirubinate pigment

Sludge

199
Q

Acute anal fissures are present for less than __. What are the Sx of anal fissures?

A

8wks
Anal pain at rest
Bleeding
(also they’re visible)

200
Q

When should we start CRCa screening in an ASx, non-risky pt?

A

50yo, or 45yo if they’re African-American.

201
Q

What would internal hemorrhoids look like on anoscopy?

A

Bulging blue-purple veins

202
Q

Besides the typical H/H, inflam markers, and WBC, what is an additional good choice of lab to order for a Crohn’s pt? What is it?

A

Fecal calprotectin (a marker of intestinal inflam)

203
Q

The gold standard for celiac Dx is …

A

Duodenal Endoscopy + Bx (no villi, hypertrophic crypts)!

204
Q

What can you do to help ensure hernias won’t recur?

A

Put the mesh in right and go for lap if you can.

205
Q

Which type of hemorrhoids are painful? What are they made of?

A

External, especially with clots

Squamous ep

206
Q

The three parts of the gallbladder are the __, __, and __, and together they are responsible for…

A

Neck, body, fundus

Store bile, which helps break down fat.

207
Q

How does cholestasis present?

A

RUQ colicky pain
Dark urine
Jaundice
Wt loss

208
Q

Besides the aforementioned colonoscopies, what should you do to monitor your Crohn’s pt?

A

Screen qyr for active infections like TB/HIV/Hep etc.

209
Q

Open, lap, __, and __ are all options for hernia surg.

A

Open tension-free mesh

Open primary approximation non-mesh

210
Q

In simplest terms, what is cholestasis?

A

Things aren’t moving at the gallbladder (obstruction, liver damage, etc.)

211
Q

What are the four places you can put a mesh?

A

Overlay - above fascia
Inlay - between fascia
Sublay - between rectus and peritoneum
Underlay - intraperitoneal

212
Q

Indirect bilirubin is aka __, and normally is…

A

Unconjugated bilirubin

What freed heme turns into, carried by proteins, to liver, small amount present in bloodstream.

213
Q

What are the three options (and their timeline) for CRCa detection?

A

FIT qyr
gFOBT qyr
FecalDNA q1-3yr

214
Q

Tx anorexia by…

A

Referring to psychiatrist only.

215
Q

Most important things to note on LGIB HxPE:
HPI -
PMHx -
Rx -

A

HPI - Sx before? painless = div., change in bowel habits = CA, abd pain/diarrhea = colitis
PMHx - coagulopathy, diverticulosis, prior GIB
Rx - NSAIDs, anticoags, antiplts

216
Q

2 big clinical features of anorexia?

A

Wt loss –> 15% below expected wt

Amenorrhea (at least 3 cycles) - does not usually occur in bulimia

217
Q

Protein loss starts in ___ and progresses to….?

A

Skeletal muscle –> liver/GI/kidney/heart/resp/B and T cells

218
Q

Who does Lynch Syndrome present in most, and where? What is it?

A

~45yo men>women
R colon
polyp —> CA much more likely!

219
Q

FJP is usually ASx, but if it’s not, what 3 Sx are most likely to present?

A

Painless rectal bleeding
Rectal prolapse
Failure to thrive

220
Q

True anal cancer can occur in what three types of tissue down there? Which is the most common to get CA in? What is each type of CA called?

A

Squamous (common - SCC)
Transitional (common - SCC)
Glandular (adenocarcinoma)

221
Q

Pale conjunctiva = ___.

A

Chronic blood loss.

222
Q

Who gets UGIB?

A

Older, men>women

223
Q

(this is gonna be a real stretch on the way I memorize it) Which monoclonal antibody Rxs act on EGFR? VEGF?

A

Set the pan for an egg fry (Cet- and Pan- for EGFR)

Bev is a vegetable (Bev- for VEGF)

224
Q

How does pilonidal disease happen?

A

Opened/damaged pores become clogged with hair and debris and get infected

225
Q

What is the main difference between primary and secondary bile acids?

A

Primary - made in liver

Secondary - made in colon

226
Q

When should we start CRCa screening in an African-American pt who is NOT high-risk?

A

45yo

227
Q

Besides trauma and FamHx, risk factors for groin hernias include chronic __, chronic __, and smoking.

A

Cough

Constipation

228
Q

Repair hernias >__. At what point does repair become difficult?

A

2cm

>10cm is hard to fix

229
Q

IBD causes what type of polyp? What do they look like?

A

Inflammatory pseudopolyps (look like irregular islands)

230
Q 
Most important things to note on UGIB HxPE:
HPI -
PMHx -
Rx -
SocHx -
A

Onset, BRBPR/hematochezia, melena/coffee grounds vs bright red blood
PMHx - PUD, GERD, cirrhosis, H. pylori, portal HTN, bulimia.
Rx - NSAIDs, PPi, anticoags
SocHx- EtOH/cigs/illicit drugs

231
Q

What am I looking for on a Crohn’s Bx?

A

Ulcers, strictures, skip lesions!

232
Q

Sx of VitB12-def are __ of tongue, __ neurologically, and ___ anemia.

A

Glossitis
Paresthesia/dementia/balance issues
Slow-onset

233
Q

In what circumstances would we give abx to Tx pilonidal disease?

A

Basically, if they are at high risk for big infections.

Immunosupp, endocarditis risk, have cellulitis around it, or it’s dirty

234
Q

A Grade II internal hemorrhoid looks like…

A

A bulge that prolapses with straining but reduces spontaneously after

235
Q

Your Crohn’s pt gets a fistula. Assuming your Tx does not fail, how do you Tx it?

A

TPN + monoclonal antibody x 10wks

236
Q

Which type of groin hernia is worse? Why?

A

Femoral: rarer, and can get incarcerated/strangulated

237
Q

Besides an infected anal crypt gland, what are some etiologies of anal fistulas?

A

COLARR

Crohn's
Obstetric injury
Lymphogranuloma venereum (d/t chlamydia)
Actinomycosis
Rectal foreign body
Rectal proctitis
238
Q

Your pt has an immediate family member who was Dx’d with CRCa at age 60+. Are they high risk? What should we do screening-wise?

A

Not risky, screen just like any random healthy dude

But when you do get around to screening, use colonoscopy.

239
Q

What is Parks 1?

A

Intersphincteric (dentate to anal verge)

240
Q

You get a pt’s labs back, and everything is normal except their total bilirubin, which is elevated. What’s going on?

A

Isolated hyperbilirubinemia

241
Q

Besides being villous, what characteristics of a polyp make ya antsy for CA?

A

Hi-grade dysplasia

>#1 of >1cm or >#3 of any size

242
Q

Your Crohn’s pt gets a perianal fissure. How do you Tx it?

A

Flagyl or cipro.
If that doesn’t work, tacrolimus or 5-ASA.
If that doesn’t work, monoclonal antibody.
If that doesn’t work, surg.

243
Q

If a fistula is not involving the sphincter muscles, what is it called, and what Parks classification is it?

A

Superficial

None

244
Q

How should we Tx CRCa?

A

CUT IT OUT! All stages, all locations!
Bonus: Chemo for Stage III-IV

[“Chemo + rad for Stage II-IV” is for RECTAL CA. “Stage II only gets surg” is for COLON CA.]

245
Q

What am I looking for on a double Ba enema?

A

Apple-core narrowing + marked distention

246
Q

SrFerritin

A

<12 ng/mL

<30 ng/mL

247
Q

Besides developing countries, where else might you see Kwashiorkor?

A

Hypermetabolic state pts - trauma, sepsis, burns

20% of hospitalized pts!

248
Q

What is the gold standard for Crohn’s Dx?

A

Colonoscopy + Bx

note - CT might help

249
Q

UC Dx depends on exam, colonoscopy, and histology. What would we be looking for on histology?

A

Crypt abscesses

Plasma cells/eosinophils/lymphocytes

250
Q

What are some strategies for preventing polyps?

A

Low-fat diet, normal BMI, dec EtOH/cigs

ASA (or COX-2i in advanced adenomatous polyps)

251
Q

Folic acid-def is usually d/t…

Who is most at risk?

A

Lack of dietary intake

Preg - need 5-10x normal intake!

252
Q

Oops, your pt who was scheduled for a lap chole actually isn’t fit for surg, they’re super risky. What do you do instead?

A

Perc drainage

253
Q

Anal fissures are usually where? What are they?

A

Posterior midline

Distal longitudinal anoderm tear

254
Q

If a CRCa detection test is positive, what do you need to make sure is also on file?

A

A CRCa preventative screening test

255
Q

2/3 of all colonic polyps are __ polyps. Why is that bad?

A

Adenomatous ==> adenocarcinoma in 7-10yrs ==> CRCa

256
Q

If on a scope you see NO polyps or <10mm hyperplastic ones, when should you do the next scope?

A

10yrs later

257
Q

What even is an indirect inguinal hernia?

A

Protrudes @ int inguinal ring

258
Q

Where do UC and Crohn’s each occur? What layers of the GI tract does each affect?

A

UC - Affects mucosa; colon and rectum.

Crohn’s - Affects everything (transmural); entire GI tract.

259
Q

How do you Dx an anal fissure? How do you Tx it (5)?

A

HxPE ONLY

Fiber
Sitz bath
Stool softener + laxative
Topical analgesics
Topical vasodilators
260
Q

When generically screening for CRCa risk, start asking about FamHx at age __ and ask again every __.

A

20yo

q5-10yrs

261
Q

Post-op anal CA pt: Get __, __, __ q3-6mo x 5yr; get __ qyr x 3yr.

A

DRE/Anoscopy/palp of inguinal node

CT

262
Q

You get a pt’s labs back, and their alk phos is very elevated, but their AST, ALT, and total bili are within normal limits. What pattern do you see? What do you suspect?

A

Cholestatic pattern
Likely to be biliary obstruction (which is extrahepatic), or could be primary biliary cholangitis (which is intrahepatic).

(total bili does NOT have to be elevated for it to be cholestatic!)

263
Q

What 3 Rxs can cause gallstones?

A

Octreotide
Ceftriaxone
Clofibrate

264
Q

How do we monitor known FJP pts?

A

Colonoscopy q1-3yrs starting at 15yo

265
Q

Generally, what three things am I keeping an eye out for on exam if I suspect UC?

A

Abd +ttp
BRBPR on DRE
Extraintestinal stuff (like AIHA, mouth ulcers, PSC, etc.)

266
Q

5 Screening/Dx tests for polyps? Which is best?

A

FOBT –> double Ba enema –> CT colonography –> Flex Sigmoidoscopy –> Colonoscopy (GOLD STANDARD)

267
Q

AST is found in ___, is elevated ___, and normal value is _____.

A

Liver, muscle, pancreas, and a lot of other places.
In a 2:1 or 3:1 AST:ALT ratio in EtOHics
8-48 U/L

268
Q

What’s important to remember when doing a physical exam on a suspected hernia pt?
For women, note that…
For men, note that…

A

Have them stand up!
Women: might need U/S if it’s small
Men: you gonna have to stick your finger in their ext ring.

269
Q

What’s the recommended repair for incisional hernias <2cm?

A

mesh repair. Required for any ventral hernia >2cm.

270
Q

Most anal fissures are primary caused by trauma. What are 4 secondary causes?

A

Crohn’s
CA
STIs
Granulomatous stuff (TB/sarcoid)

271
Q

Direct bilirubin is aka ___, and normally it is…

A

Conjugated bilirubin

In bile and excreted in stool, not present in bloodstream

272
Q

On scope you did find a single (or two) small (<1cm), tubular adenomatous polyps. When do you f/u scope? In what other circumstance would you have the same f/u scope timeline?

A

In 5yrs

Ditto for nondysplasia’d small (<1cm) serrated sessile polyps.

273
Q

You know what Murphy’s sign is. What about Courvoiser’s sign?

A

That’s a palpable gallbladder d/t common bile duct obstruction.

274
Q

Most groin hernias are located on which side? What is the usual presenting complaint?

A

R

Heaviness/dull discomfort esp @ end of day/when straining + groin bulge

275
Q

You did a scope, found a large polyp >2cm, and excised it. Now what?

A

F/u scope in 3-6mo!

276
Q

How often should your CRCa (with no mets) pt get a f/u CT post-op?

A

qyr x 5yr

277
Q

__ and __ hernias occur off the midline, as well as some incisional hernias.

A

Spigelian

Parastromal

278
Q

What is the most common presenting Sx for L-sided CRCa? R-sided?

A

L-sided: bowel changes!

R-sided: iron-def anemia

279
Q

3 Sx of acute cholecystitis?

A

RUQ pain + fever + leukocytosis

280
Q

Muscle wasting usually first presents at __ and __.

A

Thenar eminence and temples.

281
Q

UC Dx depends on exam, colonoscopy, and histology. What would we be looking for on colonoscopy?

A

Diffuse, friable, erosions, bleeding, ulcers

282
Q

Two subtypes of Hamartamous Polyposis Syndromes are __ and ___. What genes are affected in each?

A

Familial juvenile polyposis (SMAD4/BMPR1a)

Peutz-Jeghers Syndrome (STK11)

283
Q

What’s the name of the protocol we use to stage severity of Crohn’s?

A

Montreal Classification (L1-4 is how much it covers; B1-3 is whether it strictures/penetrates)

284
Q

For a polyp 5-10mm, what should we do to remove it during a colonoscopy?

A

Standard snare excision

285
Q

How and where do bile salts get recycled?

A

In terminal ileum, they’re reabsorbed and put through portal circulation back to gallbladder

286
Q

How do we Tx Lynch Syndrome? How do we f/u?

A

Colectomy!

f/u c yearly/biannual scope starting at age 20

287
Q

A bad anal fissure should be treated by… Name four types.

A 
Surg!
Fissurectomy
Anal advancement flap
Botox
Sphincterectomy
288
Q

Where do we Tx anal fistulas?

A

Under general anesthesia in OR

289
Q

Before any imaging, you need to get __, __, and __, and maybe put in a __.

A

HxPE
Labs - order CBC c diff, CMP, Coags, preg.
ECG
+/- NGT

290
Q

What is an anal fistula? Why does it happen?

A

An epithelialized track across perirectal skin

From abscess rupturing or being drained

291
Q

Perianal and perirectal abscesses are usually d/t __.

A

Infected obstructed anal crypt gland

292
Q

What would prolapsed internal hemorrhoids look like on anoscopy?

A

Dark pink, glistening, +/- tenderness

293
Q

How do you Tx celiac?

A

Stop eating all gluten. + Vit supps and steroids for first bit.

294
Q

Why is the double-contrast Ba enema outdated?

A

Can only see half of polyps even >1cm

295
Q

If you found something on the scope that I haven’t already listed above, how long should we wait before a f/u scope? Like what?

A

3 years.

Generally >#2 but 1cm but <2 cm

296
Q

Besides prompt drainage, what can we do to Tx abscesses? (yeah, yeah, evidence is conflicting, whatever)

A

Cipro + Flagyl, or Augmentin

297
Q

The most common Sx of anal CA is ___.

A

Rectal bleeding!

298
Q

Besides monitoring for extracolonic CA, what routine monitorings do PJS pts need?

A

Colonoscopy q2-3yrs starting at 18yo

EGD q2-3yrs starting at age 10

299
Q

What two red flags in the FamHx would make you consider a pt a high-risk one?

A

An immediate family member with CRCa/advanced adenoma Dx’d <60yo
or
2+ immediate family members with CRCa/advanced adenoma at any age.

300
Q

Your pt has Stage IV CRCa and you are ready to add-on an Rx. What is the one situation you would not turn to a monoclonal antibody?

A

If they are NRAS+, it won’t work. Don’t bother.

301
Q

In celiac pts, __ suggests VitA-def, __ suggests VitK-def, __ suggests Fe-def, __ suggests B12/E-def, and __ suggests Ca2+-def.

A 
A: hyperkeratosis/derm herp
K: ecchymoses
Fe: cheilosis/glossitis
B12/E: periph neuropathy/ataxia
Ca2+: Chvostek/Trousseau signs
302
Q

Do po Fe2+ supp unless __, ___, or __.

A

HD pt
GI disease that inhibits absorption
Fail po iron

303
Q

What are some buzzwords that can help you differentiate abscess pain from other anal/rectal issues?

A

Constant pain not associated with BM
Pus
Fluctuance
May have fever/malaise

304
Q

Acute cholecystitis is almost always d/t ___. When it’s not, it’s called __.

A

Gallstones.

Acalculus cholecystitis

305
Q

Colonic polyps are usually ASx. If they are not, what s/s should you look out for?

A

BRBPR
Bowel habit change
Rectal tenesmus
Signs of int obstruction/LGIB

306
Q

What is Parks 3?

A

Suprasphincteric (anal crypt to ischiorectal fossa)

307
Q

What is Mallory-Weiss Syndrome? What similarity does it have with Boerhaave Syndrome?

A

Nontransmural esophageal tear

Also with vomiting; both are UGIB

308
Q

If you see a large sessile polyp >2cm on colonoscopy, how should you remove it?

A

Piecemeal excision or saline-assisted endoscopic mucosal resection

309
Q

BMR is aka __.

What’s TEF?

A

BEE

TEF (thermic effect of food)

310
Q

If you see a diminutive polyp <5mm on colonoscopy, how should you remove it?

A

Cold snare excision or cold Bx forceps

311
Q

How does acute pilonidal disease present?

A

ASx, or pain c sitting, drainage, tender/red mass

+/- fever if unTx’d

312
Q

You get a pt’s labs back, and their alk phos is very elevated, their AST, ALT, and total bili are mildly elevated. What pattern do you see? What do you suspect?

A

Cholestatic pattern

Could be biliary obstruction (which is extrahepatic), or primary biliary cholangitis (which is intrahepatic).

313
Q

Your Crohn’s pt gets a perianal abscess. How do you Tx it?

A

CT, then broad-spectrum ABx, then perc drainage or surg.

314
Q

What four criteria are necessary for FJP Dx?

A

FamHx
+ Genetic test
>#5 juvenile polyps
In multiple places of GI tract (including colon)

315
Q

Complications of bulimia? (5)

A 
Poor dentition
Electrolyte abnormalities
Gastric dilation
Constipation
Pancreatitis
316
Q

How do you decide how to Tx a hernia?

A

Based on timeline of Sx.
<6hr = it’s a strangulation => Surg
Anything later = uncomplicated fem/inguinal => elective surg (or truss in men)

317
Q

‘Diffuse inflammation’ makes you think what type of IBD? Where is the other one’s inflammation?

A

UC is diffuse.

Crohn’s is skip lesions, not diffuse.

318
Q

How do we treat Grade I-II internal hemorrhoids?

A

Sclerotherapy

319
Q

How often should your CRCa (who also had mets removed) pt get a f/u CT post-op?

A

q3-6mo x 2yr (conveniently the same as your physical exam f/u)
then
q6mo x 5yr

320
Q

What’s important to know about B12-def replacement?

A

Must be monthly for a lifetime.

321
Q

When Dx’ing celiac, which Ig is important to get?

A

IgA! antibodies or def = likely

322
Q

What makes up the common bile duct?

A

Cystic duct + hepatic duct

323
Q

Gastric vs duodenal ulcers

A

Gnawing/burning pain is shortly after meals for gastric, 2-3hr later for duodenal.
Gastric is more common in PUD.

324
Q

We know cholangitis is pretty serious stuff. What lab values are wack? What Rxs should you start right away?

A

WBCs elevated

so… hang IV cipro + flagyl, or gentamicin + ampicillin

325
Q

You started your cholangitis pt’s IV abx. Now what?

A

ERCP stat, they’ll send them for lap chole soon after.

326
Q

PSC is a very rare, diffuse inflam/fibrosis/stricture of the entire biliary system. Who gets it?

A 
UC PATIENTS (and some Crohn's ones, and if certain PSC genes run in the family)
20-50yo men > women
327
Q

Sx of PSC include fatigue, indigestion, __, __, and __.

A

Anorexia, Pruritis, Progressive obstructive jaundice

328
Q

What two labs will for sure be off in PSC? Why?

A 
Alk Phos high (because this is biliary)
Albumin low (no protein from diet because of malabsorption)
329
Q

Besides checking genetic/autoimmune stuff, how do we Dx PSC? (3)

A

ERCP
MRI
Liver Bx

330
Q

What will a PSC liver Bx look like?

A

‘onion skinning’

331
Q

Most important complication of PSC to note?

A

Cholangiocarcinoma!

332
Q

PSC will kill your pt in about 15 yrs. In the meantime, how do you Tx it if acute? If chronic?

A

Acute - cipro

Chronic - dilation/stent, or resecting any strictures

333
Q

How do your Tx plans change if someone’s got PSC AND cirrhosis?

A

Liver transplant is your only option.

334
Q

What prevents doudenal juices from refluxing back up into the ducts?

A

Sphincter of Oddi

335
Q

What 3 hormones are released by the pancreas?

A

Insulin, Glucagon, SST

336
Q

The most common cause of chronic pancreatitis is…

A

EtOH!

337
Q

The most common causes of acute pancreatitis are…. (10)

A 
I GET SMASHED
Infections (mumps/CMV/etc)
Gallstones
EtOH
Trauma
Smoking
Malignancy
Autoimmune
Scorpions ?? :0
Hypertrigs/hyperCa2+
ERCP complication
Drugs (valproate, azathioprine, celecoxib, isoniazid, weed)
338
Q

The most life-threatening complication of acute pancreatitis is ___, such as __ and __.

A

Multisystem organ failure: renal failure, ARDS (think: pancreas is right by lungs/diaphragm!!)

339
Q

Pancreatic necrosis is a complication of ___ and requires what kind of Tx?

A

Acute pancreatitis

Perc drainage +/- abx

340
Q

Acute pancreatitis (not the severe cases, just in general) present as…

A

N&V, epigastric pain maybe rad to back, with relief upon tripoding; jaundice

341
Q

Severe acute pancreatitis presents as… (5ish)

A

Grey-Turner and Cullen’s signs
Tachypnea
Hypoxemia
Hypotn

342
Q

What is Grey-Turner sign? Cullen’s sign?

A

G-T - Flank ecchymosis

Cullen - Periumbilical ecchymosis

343
Q

What lab values are likely to be high in acute pancreatitis? Are those also high in chronic pancreatitis?

A

Amylase and lipase!! ALT/alk phos/total bili if d/t gallstone obstruction; fasting trigs if d/t HLD; WBCs if d/t infection.

Chronic pancreatitis looks pretty darn normal on labs. Secretin up once 60% of pancreas is dead.

344
Q

Dx of acute pancreatitis requires 2 or more of the following:

A

Classic pain presentation
Lipase and/or amylase >3x ULN
Contrast CT confirmation

345
Q

You Dx a pt with acute pancreatitis. Now what?

A

Admit them, IVF/NPO/analgesic/antiemetic. Figure out cause. Serial labs to watch for renal failure or fluid overload.

346
Q

The algorithms for acute pancreatitis include Ranson, Apache II, SIRS, and BISAP… but only SIRS is bolded on her ppt so how about you just tell me about that one.

A

Systemic Inflam Response Syndrome Score: How severe is the pancreatitis?

  • high or low body temp
  • tachycardia
  • tachypnea
  • some lab value stuff
347
Q

The Atlanta Classification for acute pancreatitis, in a nutshell, says it’s mild if __, moderate if __, and severe if __.

A 
Mild = no organ failure
Moderate = transient organ failure, <48hr
Severe = persistent organ failure, >48hr
348
Q

Holla at me with three big complications of chronic pancreatitis.

A

DM
CA
Becoming a drug addict

349
Q

Order ___ to confirm Dx of chronic pancreatitis.

A

Abd CT!

350
Q

Tx chronic pancreatitis with lifestyle changes, __ for steatorrhea, ___ for stones/pseudocysts/strictures, or ___ for major fix.

A

Pancreatic enzyme
Endoscopy
Whipple/total pancreatectomy/islet cell transplant

351
Q

Diverticulosis occurs mostly in the __ colon and in ___ pt popn.

A

Sigmoid

Old, Western-diet-eating

352
Q

Dx diverticulousis with __.

Dx diverticulitis with __.

A

A colonoscopy!!!

Abd/pelv CT with IV contrast +/- po contrast!

353
Q

Describe the abd pain and tenderness associated with diverticulitis.

A

LLQ

Constant pain over several days with abd rigidity and rebound tenderness

354
Q

Besides imaging, what should you order when working up a suspected diverticulitis pt?

A

Labs! CBC with diff, BMP, U/A.

355
Q

Most diverticulitis pts are acute and uncomplicated, which means you can Tx them without surg. What three complications would make you send them to surg?

A
  • Abscess (IR drain)
  • Bad obstruction (urg or emerg surg)
  • Free perf (emerg surg)
356
Q

Non-surg, admitted acute diverticulitis pts get __ for the infection, __/__/__, and put NPO.

A

abx- Cipro (or CPN) + Flagyl is as always a good choice; could do augmentin, ertapenem, or Zosyn.

IVF/IV analgesic/IV antiemetic

357
Q

Classify diverticulitis based on the __ System. What are your surgical options?

A

Hinchey
One-step: colon resection + primary anastomosis.
Two-step: those, but separately and with some -stomy’s.

358
Q

For a new diverticulitis Dx, schedule a f/u colonoscopy in ___ unless…
Why?

A

6wks, unless they had one within the last yr

r/o CRCa and monitor diverticula

359
Q

The main source of diverticular bleeds is…

A

R colonic diverticula

360
Q

Diverticular bleed pts’ labs might have __ H/H, but should have normal…

A

Low

Normal BUN:Cr and MCV!

361
Q

Surprise, get a colonoscopy to Dx diverticular bleeds. What are two other options?

A

Nuclear scintigraphy or angiography

362
Q

How do I stop a diverticular bleed?

A

It should stop itself.

363
Q

What if the diverticular bleed does not stop itself?

A

2x lg-bore IV
IV NS, PRBC
T&C
could NGT but nah
GI will fix with colonoscopic epi or tamponade
… or they could do angio
… or they could do a colectomy if poop hits the fan

364
Q

The appendix is a __ ___.

A

True diverticulum.

365
Q

Who gets appendicitis?

A

Men > women (but both), ~10-20yo

366
Q

Appendicitis is usually from an obstruction. When that obstruction is caused by bacteria overload, which bacteria are usually responsible? (4, think GI)

A

Pseudomonas
E. coli
B. fragilis
Peptostrep

367
Q

Briefly describe the progression of appendicitis pain and Sx.

A

Periumbilical colicky pain –> one vomit –> RLQ dull constant pain
(with nausea and anorexia the whole time)

368
Q

You know the physical exam tests for appendicitis (Rovsing/obturator/heel tap/psoas/pointing/McBurney ttp). What labs and imaging studies support your clinical Dx?

A

CBC with diff, electrolytes, LFTs, U/A

AbdXR (free air near appendix, appendicolith); U/S, CT

369
Q

Tx appendicitis with an appy (duh) - open or lap. How do you prep them in the meantime?

A

NPO
IVF/IV abx (3rd-CPN or gentamicin + Flagyl)
Call OR to let them know

370
Q

In what three situations would we NOT do an appy?

A

P-lease don’t operate if:

  • Peritonitis
  • Presence of appendix mass
  • Problem fixed itself
371
Q

The ‘midgut’ (sm int, __, and __) gets supplied by which artery?

A

sm int + ascending colon + first 2/3 transverse colon

SMA

372
Q

Two key features of SBO on exam are…

A

Distention

Tinkly sound

373
Q

Two key features of small bowel perf/ischemia on exam are…

A

Fever

Peritonitis

374
Q

The overall most common cause of SBO is __. What about in the Western world?

A

Overall - post-op adhesions

USA - hernias

375
Q

SBOs can be __, __, or __.

A

Intraluminal, intramural, extramural

376
Q

Name two examples of extramural lesions that cause SBO.

A

Hernias and adhesions

377
Q

Name four examples of intramural lesions that cause SBO.

A

That’s structural stuff- like volvulus/intussusception, or Crohn’s/stricture.

378
Q

Name four examples of intraluminal lesions that cause SBO.

A

That’s actual objects- like bezoars, parasites, foreign bodies, or stones.

379
Q

What happens above and below the SBO in a simple SBO?

A

Above - flaccidity

Below - rigidity

380
Q

SBOs can be simple, __, or __.

A

Closed-loop

Strangulated

381
Q

While your imaging of choice for SBO is an abd XR, what situations might make CT be a good choice?

A
  • if SBO is d/t adhesions, it’ll fix it.

- can confirm if pt is complicated enough to need surg.

382
Q

What can a CBC tell you in an SBO case?

A

Inc WBC –> think ischemia. Get to surg!

Dec MCV/Hgb –> think CA obstruction

383
Q

What can a Chem-7 tell you in an SBO case?

A

Electrolyte/renal failure
LFTs might inc
Amylase - a lot of the stuff that causes SBO can also cause pancreatitis

384
Q

What can an ABG tell you in an SBO case?

A

Metabolic acidosis can happen late-stage if their int is ischemic

385
Q

Your SBO pt has a normal set of labs except– oh no, their lactate level is elevated!

A

Don’t care.

386
Q

__, __, and __ will get me to throw my pt in surg’s direction faster than Brady can find Gronk in the red zone.

A

Irreducible hernia
Perf
Suspected strangulation/ischemia

387
Q

Assuming my SBO pt’s surg is NOT urgent/emergent, what should I do to prep them for the OR?

A

NPO
IVF with Is&Os (no abx)
NGT to stomach only

388
Q

Lap surg sounds good for SBO pts. Except for which four types of pts…?

A

No surg AT ALL for:

  • already post-ops
  • recurrent SBO
  • post-rad
  • carcinomatosis pts (rare peritoneal CA)
389
Q

Post-op paralytic ileus is basically gastroparesis for the small bowel. What do you do if your pt gets it?

A

Watch and wait, Tx any electrolyte/acid-base issues
D/c opioids
NGT PRN to decompress abd

390
Q

Mesenteric ischemia is d/t…

Ischemic colon is d/t…

A

SMA or SMV occlusion/thrombosis

Idiopathic

391
Q

SMA occlusion could be the result of an embolism (d/t __, __, etc) or a thrombus (d/t __, etc)

A

MI, AFib

Atherosclerosis

392
Q

NOMI (____) is d/t __ + ___ + __.

A

Nonocclusive Mesenteric Ischemia

athero + shock + vasopressor

393
Q

The big Sx of mesenteric ischemia on exam is:

A

Acute/constant periumbilical PAIN OUT OF PROPORTION

394
Q

For mesenteric ischemia, you want __ and __ for labs, and what for imaging?

A

CBC and Chem-12

Mesenteric angio, ideally.

395
Q

Let’s assume you can’t get a mesenteric angio. What are your other two imaging options, and what would you expect to see on each if your pt does indeed have mesenteric ischemia?

A

XR - thick and thumbprinted

CT - thick, dilated, hematoma, pneumatosis

396
Q

Tx mesenteric ISCHEMIA (not infarct) with __, __, and __!

A

IVF/PRBC
Anticoags
Glucagon or other vasodil

397
Q

Your pt with confirmed mesenteric ischemia suddenly gets a fever, and peritoneal signs. What happened? What do you do?

A

That’s an infarct, sir!

Emerg lap surg!! + vasodil and f/u surg tomorrow

398
Q

Ischemic colitis usually occurs in who and where?

A

Old people! L colon.

399
Q

Give me like 4 reasons why ischemic colitis happens.

A

MVT
AFib
Hypotn
s/p AAA or MI

400
Q

What are the ‘watershed areas’?

A

Splenic flexure + rectosig junction

401
Q

The physical exam for ischemic colitis is pretty nonspecific… what labs might help Dx?

A

Stool Cx
ABG- metabolic acidosis
CBC - WBC >20,000

402
Q

The physical exam for ischemic colitis is pretty nonspecific… what imaging might help Dx?

A 
AbdXR
Contrast CT (thick, seg, strands; gas in veins later on)
Endoscopy
403
Q

Tx for ischemic colitis is supportive (eg __, __, __) unless it gets bad, then do a lap resection.

A

IVF, abx, NGT if ileus.

404
Q

Most common cause of toxic megacolon is ___! Could also be viral (like __), parasitic (like __), or bacterial, like…

A

Crohn’s and UC!
CMV colitis
Cryptosporidium
C. Diff! Salmonella/shigella, campylobacter

405
Q

Toxic megacolon visible Sx are __ and __.

A

Distention and Diarrhea.

406
Q

What do you NEED to Dx toxic megacolon?

A

IMAGING EVIDENCE + THREE OR MORE OF:

  • Fever
  • Tachycardia
  • Anemia
  • WBC >10,500

+ one or more of: AMS, hypotn, dehydration, electrolyte issue.

407
Q

The operation for toxic megacolon (subtotal colectomy with end ileostomy) kills half the pts on the table, so instead, we like to Tx it with supportive measures. Tell me about those.

A 
IVF
IV abx if C.diff- Vanco po + Flagyl
IV steroids if IBD
NPO
NGT or nah.
408
Q

Pancreatic CA usually occurs in who?

A

Men>women (but both) >45yo who smoke, have DM, have chronic pancreatitis, or a FamHx.

409
Q

Your pt comes in with unintentional wt loss, new DM, and jaundice. What are you thinking?

A

Pancreatic CA in the head of the pancreas

410
Q

Your pt comes in with unintentional wt loss, new DM, and epigastric pain. What are you thinking?

A

Pancreatic CA in the body or tail

411
Q

If you suspect late-stage pancreatic CA, what three things do you expect might be abnormal on your physical exam?

A

Ascites
Palpable mass
Courvoisier’s sign

412
Q

What is Courvoisier’s sign?

A

You can palp a GB but its nTTP. Oh, and your pt is yellow.

413
Q

What two labs would you loveee to get to support your Dx of pancreatic CA? What about imaging studies?

A

LFTs and a CA 19-9

Let’s do a CT, U/S (either endoscopic or nah), and maybe an MRI.

414
Q

Your choices for pancreatic CA Tx include…

A

Just surg. Nothing else. But, you do have options there!:
In the head? –> Whipple!
In the body/tail? –> distal pancreatectomy.

415
Q

Most pancreatic CA is ___ tumors in the ___ of the pancreas.

A

Ductal adenocarcinoma

Head/neck only

416
Q

In order of most to least likely, what four places does pancreatic CA love to metastasize to?

A

Liver
Peritoneum
Lung
Adrenals

417
Q

Good news for your pt– the pancreatic tumor you Bx’d came back as ___, the benign kind.

A

Serous cystadenoma woot woot!

418
Q

__ and __ are premalignant pancreatic tumors.

A

IPMN and mucinous cystadenomas

419
Q

Most cases of viral diarrhea are __.

Most cases of bacterial diarrhea are __.

A

Norovirus

Campylobacter

420
Q

Most cases of diarrhea are infectious.
Most cases of infectious diarrhea are ___.
Most cases of severe diarrhea are ___.

A

Viral

Bacterial

421
Q

Persistent and chronic diarrhea is most likely…

A

Non-infectious

422
Q

Name the four virus families that cause infectious diarrhea.

A

Norovirus!
Astrovirus
Rotavirus
Adenovirus

423
Q

Small bowel diarrhea is more likely to look __ while large bowel diarrhea is more likely to look __. What type of diarrhea (ie, enterotoxic or invasive) is more likely in each?

A

(Rice) watery, lots of it, no fever - enterotoxic

Bloody/mucoid, little bit of it, fever - invasive

424
Q

Enterotoxic diarrhea includes bacterial causes like __, ___ and __, and parasites like __.

A

C. diff/E. coli/Cholera

Giardia

425
Q

N/V/D within 6 hrs of eating shellfish (etc) suggests __ or __ is to blame.

A

S. aureus, B. cereus

426
Q

N/V/D within 8-16 hrs of eating shellfish (etc) suggests __ is to blame.

A

C. perfringens

427
Q

> 16 post-ingestion of bad food, N/V/D suggests…

Vomiting means __ usually.

A

other viral or bacterial infection

Vomiting means Viral!

428
Q

Diarrhea that presents after a petting zoo visit makes you suspect…

A

Salmonella

429
Q

Infectious diarrhea is your guess for Dx. What labs do you want?

A

C&S (for bacteria)
C. diff tox (if suspected)
O&P if parasite (if giardia suspected, etc)
Fecal leukocytes

430
Q

What is better than fecal leukocytes but expensive AF?

A

Fecal lactoferrin

431
Q

Your first Tx priority in diarrhea is…

A

IVF and electrolytes! Or ORS!

432
Q

We don’t want diarrhea pts to eat anything, right?

A

No. BRAT diet (bananas, rice, applesauce, toast)

433
Q

Norovirus Sx are ___, ___, and ___. They start after about ___hrs. Something about cruise ships. Sx stop after…

A

Acute-onset N&V, watery diarrhea, abd cramps

12-48hrs
24-72hrs

434
Q

Which four abx cause C. diff???

A

Clinda!
Fluoroquinolones
PCNs
CPNs

435
Q

What abx Tx C. diff??

A

Flagyl q8hr or Vanco po!

436
Q

Campylobacter comes from ___, Sx are __ and __, and it is invasive. How do we Dx it?

A

Undercooked meat
Abrupt-onset abd pain and bloody diarrhea
Stool Cx - because it looks like appendicitis.

437
Q

Are salmonella and shigella enterotoxic or invasive? What does their diarrhea look like?

A

Invasive! = bloody diarrhea! (pea soup for salmon)

438
Q

What is important to note about the Tx of shigella and E. coli?

A

Hemolytic-Uremic Syndrome (ARF, Hemolytic Anemia, Thrombocytopenia) = NO ABX!!!

439
Q

How is shigella spread? How do we Dx it?

A

Fecal-oral (esp. those into anal sex)

Stool Cx

440
Q

What scrip do you give to someone who wants to prevent traveler’s diarrhea?

A

ppx Cipro (anti-shigella, anti-E. coli which is most common cause)

441
Q

Describe the diarrhea of cholera. Why is it so scary? How do we Tx it?

A

Massive rice-watery
Hypovolemic shock within 24hr
Tx- IVF + abx

442
Q

Intestinal entamoeba: invasive or enterotoxic? What are its Sx?

A 
Starts infective (cyst form) --> invasive (trophozoite form)
Invasive! = bloody diarrhea.  Scary version --> fulminant colitis.
443
Q

Who gets intestinal entamoeba? How do we Dx and Tx it?

A

Nursing home/prisoners
O&P + SrAntigen
Flagyl!

444
Q

The most common cause of foodborne diarrhea in the US is __. How do we Tx it?

A

Cryptosporidium

Nitazoxanide (good Nite parasite)

445
Q

Giardia diarrhea is special because…

We Tx it with __, but…

A

It’s yellow and smells GROSS

Flagyl or Nitazoxanide (good Nite parasite), but Sx last up to 6wks more

446
Q

Noninfectious causes of diarrhea include __, __, and __ in old pts.

A

IBD, IBS, and fecal impaction

447
Q

How often do you have to have IBS Sx for it to count?

A

At least 1 day per week in last three months

448
Q

We Tx IBS with lifestyle changes. But what Rxs can we add for IBS-C?

A

PEG, Lubiprostone, Linaclotide

449
Q

Steatorrhea indicates ___.

A

MALABSORPTION.

450
Q

Gold standard test for malabsorption is __.

A

Quantitative Stool Fat Test!

451
Q

po > IV for diarrhea Tx, so shotgunning a Gatorade is as good as an IV NS bag, right?

A

Gatorade is a lie.

But po > IV is not.

452
Q

Why is water not a good ORS?

A

Diseased sm int will NOT absorb water without salt or sugar to transport it!

453
Q

What’s my IVF target for a severely dehydrated pt?

A

200mL/kg body weight of oral or IV fluid replacement in 24 hours… yikes

454
Q

Loperamide is NOT INDICATED if…

A

It’s a bacterial diarrhea - we want to get that stuff out!

Clin Med (4 decks)

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