GI Exam Flashcards
1
Q
What’s the recommended repair for umbilical hernias <2cm?
A
simple suture, +/- mesh
2
Q
Extrasphincteric is Parks __ and is located…
A
4
High anal canal to buttock’s skin
3
Q
The big three s/s for cholangitis are ___, __, and ___. That’s called…
A
CHARCOT’S TRIAD: fever + jaundice + severe RUQ pain
4
Q
Which GIB is more common?
A
Upper (1/1000 people a year)
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.
6
Q
What happens if you don’t drain your pt’s abscess?
A
–> Sepsis!
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.
8
Q
One of the biggest risk factors for Crohn’s is __. Another is a PMHx of __ infection.
A
FamHx!!
Gastroenteritis infection
9
Q
CBC of GIB initially is normal. Why? When do you repeat?
A
Catecholamines. Repeat q2-8hr
10
Q
What is the only type of neoplastic polyp we discussed?
A
Adenomatous!
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
12
Q
What are the extraintestinal Sx of celiac?
A
FASHON Fe-def anemia Abd protuberance Skin stuff Hormonal stuff Osteoporosis Neuro stuff
13
Q
A Grade I internal hemorrhoid looks like…
A
A non-prolapsed bulge only visible on anoscopy
14
Q
When would we use monoclonal antibodies in CRCa Tx?
A
Stage IV as an add-on to traditional chemo
15
Q
Give me the quick-and-dirty lowdown on irinotecan.
A
Use it as part of triple chemotherapy.
Topo1i.
16
Q
Why do UGIBs occur? (4ish)
A
PUD (GASTRIC > duodenal)! Esophageal varices Erosive Esophagitis/gastritis CA/polyps etc.
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.
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!!!
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
20
Q
5ish Causes of LGIB?
A
LGIB - DIVAS
DIVERTICULOSIS BLEED Inflammatory conditions (IBD, CA) Vascular ischemia Anorectal stuff (fissures etc) S/p surg
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)
22
Q
How do we Tx advanced (Stage IV) anal CA?
A
Palliative systemic chemorad :/
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
24
Q
If painful BM is occurring with fever, night sweats, and weight loss, think…
A
Colon CA!
25
A Grade IV internal hemorrhoid looks like...
Prolapsed, irreducible, may strangulate
26
HxPE can pretty much nail an anal fistula Dx, so why might I order imaging?
For complex ones, esp. if my pt has Crohn's.
27
Which IBD is friable? Which one has erosions?
UC for both.
28
When staging CRCa, how many lymph nodes do you need to dissect?
12+!
29
What abx would we give to Tx pilonidal disease, if that's determined to be needed?
Cefaz + Flagyl
30
What is CEA and what would we use it for with regards to CRCa?
Carcinoembryonic antigen - get pre and post-op to monitor recurrence
31
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 ____.
GGT
+ Alk phos/ - GGT = Bone issue.
+ Alk phos/ + GGT = Liver issue.
32
We LOVE colonoscopies. What are the few risks of it?
Anesthesia issues
Perf/significant bleeding
Old pts - dehydration/electrolyte issues
33
What will ECG of GIB show?
Nonspecific, isoelectric or flipped T waves
| and r/o CAD etc
34
Name the 5ish more strongly associated extraintestinal manifestations of UC.
```
APPLE
Ankylosing spondylitis
Pyoderma gangrenosum/mouth ulcers
PSC
Lots of joint pain
Erythema nodosum
```
35
If you found >10 adenomas on a scope, when should your next f/u scope be?
3 yrs later or less!
36
What's the difference between Kwashiorkor and Marasmus?
Kwashiorkor - adequate kcal, inadequate protein (more developing countries)
Marasmus - inadequate protein AND kcal (more emaciated)
37
Give me the quick-and-dirty lowdown on capecitabine.
Breaks down into 5-FU; can use instead of 5-FU+leucovorin.
38
Treat an external hemorrhoid with __, __, __, and maybe ___ drugs.
Hydrocortisone cream or suppository
Witch Hazel
Zn2+ oxide
+/- anesthetic
39
ADMIT Crohn's pts with:
Bowel obstruction
Abscess
Serious infection
Severe Sx!
40
Describe the unique pain of cholelithiasis.
Sudden-onset, intermittent epigastric or RUQ pain that may radiate to shoulder, accompanied by N&V.
41
What's the name of the protocol we use to stage severity of UC?
Montreal Classification (E1 is best, S3 is worst)
42
A pt's U/A comes back positive for albuminuria and conjugated bilirubinuria. What do they have?
Direct hyperbilirubinemia
43
How do you Dx lactose intolerance?
50mg lactose po, then Hydrogen Breath Test (+ if rise of 20+ppm in 90min)
44
What are the three classifications of abscesses? Where is each located?
Ischiorectal (aka ischioanal): within buttock, obvious red/diffuse ext findings
Intrasphincteric: between int and ext sphincters (+/- ext findings)
Supralevator: above levator (no ext findings)
45
What is the most common type of non-neoplastic polyp and what do they look like?
Hyperplastic (serrated, kind of look adenomatous, but usually <5mm by rectosigmoid)
46
Progression of Crohn's Tx, from mild to severe?
5-ASA and supportive (loperamide, BAS) --> short-course Budesonide --> MTX or azathioprine --> TNF-a blockers --> anti-integrin (Vedolizumab)
47
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?
Not risky, screen just like any random healthy dude
| But when you do get around to screening, use colonoscopy.
48
Don't bother screening anyone over __yo for CRCa.
85yo (over 75yo, use your discretion)
49
On your pt's coag panel, you see that their PT is high. What does that mean, and what three reasons that could happen?
Longer bleeding time/harder to clot
VitK-def
Cholestasis
Hepatitis
50
Name the three types of submucosal polyps. Are they neoplastic?
Lymphoid
Fibroma
Lipoma
NO
51
What anatomic structure determines whether a hemorrhoid is internal or external?
```
The dentate (pectinate) line
(they can also be mixed)
```
52
4 main Sx of Crohn's?
Intermittent!: lo-fever + watery diarrhea + RLQ pain + perianal stuff
53
If a FamHx makes FAP suspicious, how should we screen and when?
Starting at 10-12yo - flex sig
Genetic test
Then colonoscopy qyr once +polyps
54
How do we Dx anal cancer? (3)
Anoscopy
Rigid proctosig
Endoscopy + Bx
(ARE you going to Dx ass cancer today?)
55
Dx study of choice for suspected cholecystitis? What's another (more pricey) choice, and what does a 'positive' look like?
U/S
| HIDA: + = tracer dye doesn't enter gallbladder.
56
What is Wernicke-Korsakoff Syndrome?
Severe CNS involvement from thiamine-def.
57
~~~the gold standard for CRCa Dx is .... ~~~
Colonoscopy!
58
What is Boerhaave Syndrome?
B is for Bad!!!
Spontaneous esophageal rupture, usually after forceful emesis.
Transmural.
59
How do you diagnose a hemorrhoid?
PE + DRE + Anoscopy (all 3!)
60
What is a hemorrhoid?
A NORMAL AV tissue poop cushion.
61
Why is it called Familial 'Juvenile' Polyposis? Where does it present?
Histologically, the polyps are 'young' not advanced.
| Throughout GI tract (sm int on)
62
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?
```
CA
Fistulas that just won't quit
Abscesses
Perf
Toxic megacolon
```
63
Anal CA below the dentate line is aka ___.
Keratinizing SCC (think about it - keratin is skin/nails, so more external than internal)
64
What fatty acid is essential (dietary)?
Linoleic acid
65
What is Turcot Syndrome and what does it have to do with GI...?
Brain malignancy + GI hereditary disorder.
Ex: gliomas + Lynch Syndrome
Rare ex: medulloblastoma + FAP
66
The first enzyme to get elevated in liver damage is usually __.
GGT
67
UGIB Tx (fyi)
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
68
Tx protein-caloric malnourishment by...
Calling a nutrition consult.
69
What all is the colon responsible for absorbing? Excreting?
VitK, salt, water
| Excrete: potassium
70
1,25-dihydroxyvitD does __ and __.
Absorption of dietary Ca2+
| Stimulating osteoclasts
71
3 stages of Fe-def?
Depletion of iron without anemia
Anemia with normal MCV
Microcytic, low-ret anemia.
72
__ and ___-def cause macrocytic anemia.
Folate-def and B12-def!
73
How often should a UC pt with PSC get a colonoscopy? Why?
qyr!
| Cholangiocarginoma risk
74
B12-def is most common in __, ___, and ___.
Vegans, EtOHics, s/p gastric/ileal surg pts!!!
75
VitD-def is the most common cause of...
Osteomalacia
76
How often should your CRCa pt get a f/u physical exam post-op?
q3-6mo x 2yr
then
q6mo x 3yr
77
Thiamine-def is usually d/t...
| What is a common co-deficiency?
Chronic EtOHism
| Folate-def
78
Suppurative cholangitis: pus comes out of...
the ampulla of Vater
79
What's my horrible way to remember the special characteristics of Crohn's?
```
Crohn is a fatass.
Fistulas
Abscesses
Transmural
Adhesions
Sinus tracts
Strictures
```
80
Inherited polyposis syndromes are __ __ pattern.
Autosomal dominant
81
Where do femoral hernias protrude?
@ femoral ring... duh.
82
Sx of hemorrhoids?
ASx!
| Or, BRBPR painlessly with BM
83
3 things to look for on the physical exam of a suspected anal CA pt?
Bleeding + Condylomata + Mass on DRE
84
What's the difference between a perianal abscess and a perianal fistula? What's important to note about abscesses?
Abscess = acute
Fistula = chronic
Drain abscesses promptly!
85
Give me the quick-and-dirty lowdown on leucovorine.
Use as a co-px for 5-FU to make them bind better.
86
Most hereditary polyposis syndromes have what type of polyp? What does it look like? Are they neoplastic?
Hamartamous (disorganized)
No, but they CAN lead to CRCa if they get dysplasia'd
87
```
A cholestatic pattern on labs puts these five disease processes on your DDx:
Primary _____
Primary _____
_____ CA
_____carcinoma
______.
```
- Primary biliary cirrhosis
- Primary sclerosing cholangitis
Pancreatic CA (don't fuck with the pancreas. Evil spirits)
Cholangiocarcinoma
Choledocholithiasis
88
Charcot's triad + ___ + ___ = a major endoscopic emerg. Together, these s/s are known as...
Hypotn + Altered mental status
| Reynold's Pentad
89
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?
3cm
Curvilinearly to posterior midline
Radially (straight line)
90
More intense hemorrhoids can be treated by...
Doppler-guided hemorrhoidectomy
91
How do we Dx pilonidal disease? What's the most common Tx of it?
HxPE
I&D under local anesthesia, packed c gauze
92
If an external hemorrhoid has a clot and it's been under 72hr, treat it by...
Wide excision + evacuation
93
Your pt has Stage IV CRCa and you are ready to add-on a monoclonal antibody. Why might you specifically pick Bev- for them?
If they are KRAS+.
94
Non-negotiable, all Crohn's pts should...
quit smoking!!!!
95
Who gets pilonidal disease?
Men > women (but both do) around 20yo, esp if overweight
96
Your pt has Crohn's. What do you want to know before you give screening advice? What IS your screening advice?
How long it's been since they started getting colitis Sx.
| 8+yrs since that? Colonscopy q1-2yr.
97
In cholecystitis, there will be leukocytosis. Fo' sho. What other four lab values *could* be elevated?
Alk phos
AST/ALT
Total bili
Amylase
98
What makes up bile?
Bile acids + cholesterol + phospholipids
99
Reeeeally low albumin in a blood sample suggests __, __, or ___.
Malnutrition
Cirrhosis
Severe hepatitis
100
What are the three options (and their timeline) for CRCa screening preventatively?
Colonoscopy q10yr
Flex sig q5yr (or q10 if + FIT)
CT colonography q5yr
101
Alk phos is found in ___, is elevated when ___, and normal value is _____.
Liver and biliary tract, bone, and a few other places.
Obstructions/stones/tumors
45-114 U/L
102
Who is most likely to get abscesses and fistulas?
Men around 40 yo!
103
Why are desmoid tumors bad?
FAP pts die from its mets.
104
Your 20yo pt has HNPCC. What is that also known as again...? Obviously they need monitoring via colonoscopy, but how often?
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.)
105
RDAs have been replaced by __.
DRIs
106
Crohn's often presents very similarly to what other GI issue?
SBO
107
Big 3 Sx of UC?
```
Bloody diarrhea (<4 is mild, >6 is severe)
Abd pain (LLQ usually)
Rectal bleeding
```
108
Hernias generally can be __ (like __ or __), or __ (like __ or __).
Groin - inguinal, femoral
| Ventral - incisional, umbilical
109
Perianal/anal margin CA occurs where?
In the skin, or just outside the squamous mucosa.
110
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?
Hepatocellular
| Intrahepatic injury
111
What's a distinguishing feature of PJS? What do its polyps look like?
Dark discolorations on skin and mucous membranes
| Hamartamous
112
A Grade III internal hemorrhoid looks like...
A bulge that prolapses with straining but requires manual reduction after
113
LGIB Tx (fyi)
Central line, T&C, IVF/blood/clotting factors
114
What is hydrops of the gallbladder?
Mucocele that forms in the gallbladder, potential complication of gallbladder surg
115
4 possible imaging studies for choledocholethiasis? Which is the most advantageous?
RUQ U/S
CT
MRCP
ERCP (good because you can add stent while there to Tx)
116
What is a direct inguinal hernia?
Protrudes @ Hesselbach's triangle (medial to int epigastric vessels)
117
If any pt over 40yo presents with hematochezia and bowel changes...
R/O CRCa!!! (scope 'em!)
118
People with FAP GET CA. Usually around age __. What are some extracolonic CA they might also get (7)?
40yo.
Pancreatic, thyroid, gastric (fundic gland), sm int (duodenal adenoma); desmoid tumor (conn tiss), CHRPE, or Turcot (rare).
119
FAP is a mutation in the __ gene that starts presenting with __ at __ yo.
APC
>100 adenomatous polyps
~16yo
120
What is the most common tip-off to Lynch Syndrome?
PMHx/FamHx of extracolonic malignancies!!! Esp endometrial carcinoma!
121
What in the heck is choledocholethiasis?
A stone in the common bile duct
122
FAP pts get fundic gland polyps. What's important to know about them?
Non-neoplastic!
| Hard to remove.
123
How do we treat Grade II-III internal hemorrhoids?
Rubber band ligation
124
Your Crohn's pt gets an SBO. How do you Tx it?
IV steroids + NG tube decompression
| surg if that fails
125
What's the order of Tx for UC, mild --> severe?
5-ASA --> Budesonide (or prednisone) --> hospitalize and IV steroids --> monoclonal antibodies --> cyclosporine --> surg.
Surg is the only actual cure.
126
We're not really sure about the pathophys of IBD, but generally throw out three keywords.
TLRs
Autoimmunity
Junction damage
127
What is the most common surg used to take out rectal CA?
Transanal excision
| runner-up: total mesorectal excision
128
New-onset anemia is ___ til proven otherwise!
A bleed!
129
Your pt *had* CRCa, but had the cancer part yanked out. Does he still need colonoscopy screening?
Yes! Do your first colonoscopy within a year of the surg, and then 3yrs after.
All good then? Repeat q5yr.
130
The most common hereditary colon CA is ___ aka ____.
Lynch Syndrome aka Hereditary Nonpolyposis CRCa
131
What do thrombosed external hemorrhoids look like?
Purplish-blue and acutely tender
132
Okay, let's be a little more specific. What kind of surg do we use to take out colon CA?
Lap or open, total or subtotal, +/- ostomy
133
CMP shows BUN:Cr ratio 20:1. Why?
Pre-renal state; digested blood proteins getting absorbed into circulation
134
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.
```
CBC
CMP
INR/coag
Fecal stool
Oral tolerance tests
```
135
What are the three general procedure choices for anal fistulas?
Fistulotomy + fibrin sealant
Fistulotomy + setons
Anal advancement flap +/- fibrin seal
136
What extracolonic malignancies are most common in PJS pts? What monitoring do they need because of that?
Breast and testicular
| So exam qyr + mammogram/breast U/S!
137
LGIB blood loss originates ___
In colon, distal to Ligament of Treitz
138
ALT is found in ___, is elevated when ___, and normal value is _____.
Hepatocytes
Hepatocyte damage
7-55 U/L (varies by pt popn)
139
Who gets ass cancer and why?
Women more often, or anyone active in anal sex, d/t HPV
140
What is Mallory-Weiss Syndrome? What similarity does it have with Boerhaave Syndrome?
Nontransmural esophageal tear
| Also with vomiting
141
Hey, what're some great ways your pt can help keep themselves from getting CRCa?
Stop smokin, drinkin, and givin yourself diabetes!
| also ASA qd...?
142
Where are four common locations for CRCa to metastasize to?
Peritoneum
Liver
Lungs
Lymph nodes
143
General Sx of UGIB? Think through effects of blood loss, then think through possible causes.
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
144
FAP pts get duodenal adenomas. Where in the duodenum do they happen?
Papilla of Vater
145
Celiac is aka __. What is it? What does it affect?
Gluten enteropathy - an immune rxn to gluten catabolite
| Affects proximal small bowel
146
How to Tx LGIB?
It usually self-resolves
147
```
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 ___.
```
Viral or autoimmune
Wilson's
Budd-Chiari, ischemic hepatopathy
148
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?
From a pelvic infection
SEVERE perianal pain, fever. +/- urinary retention
149
The most important lab when evaluating protein malnutrition is __. What are the two syndromes with lowered values of that?
Albumin
| Kwashiorkor and Marasmus
150
How does chronic pilonidal disease present?
Recurrent persistent pain
Drainage
Tender/red mass
151
LDH is found in ___, is elevated ___, and normal value is _____.
Liver and blood
Anytime there is tissue damage
140-280 U/L (fyi)
152
Normal B12 value is __.
| Peripheral smear looks like...
210 pg/mL
| Megaloblastic with hypersegmented neutros!!
153
How do you Dx each type of abscess?
Ischiorectal - visible on PE
Intrasphincteric - DRE
Supralevator - Hx, maybe DRE, usually need CT
Could also use transperitoneal or endorectal U/S
154
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)
- Make them NPO & start IVF
- Prescribe a non-morphine pain Rx (since morphine --> Sphincter of Oddi spasm)
- Start IV Flagyl + 3rd-gen CPN
155
Gastric vs duodenal ulcers
Gnawing/burning pain is shortly after meals for gastric, 2-3hr later for duodenal.
Gastric is more common in PUD.
156
Where does pilonidal disease occur?
Butt crack!!
(jk jk it's the ~intergluteal cleft~/upper natal cleft)
Both skin and SQ
157
Most important thing to be able to do in GI bleeds?
Find the bleed, stop the bleed.
158
What type of groin hernia is most common, and who gets it most often?
Indirect inguinal hernia
| 50-70yo white men > 60-80yo white women (but both get it)
159
When would UC be considered emergent? What do we do about it?
Fulminant UC/Toxic Megacolon
| Colectomy stat!
160
Give me the quick-and-dirty lowdown on oxaliplatin.
Must use as a 5-FU add-on, not alone
| ADR: periph neuropathy
161
Dx study of choice for suspected cholelithiasis? What's another (more pricey) choice?
U/S
| HIDA
162
What four things do I need to get before cutting the CRCa out of my pt?
Labs: CBC c diff, LFTs, CEA level
| To stage: chest/abd/pelvic CT
163
Sx of VitB12-def are __ of tongue, __ neurologically, and ___ anemia. (similar to folate-def)
Glossitis
Paresthesia/dementia/balance issues
Slow-onset
164
Name 5 other procedures (besides I&D) to Tx pilonidal disease.
```
Excision
Primary closure
Off-midline closure
Z-plasty
V-Y advancement flap
```
165
Pre-op, what is good to order on a RECTAL cancer pt?
Endorectal U/S
166
Inherited polyposis syndromes are really rare, so in what four circumstances would I even consider it?
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.
167
How does an anal fistula present (3ish)?
Intermittent rectal pain that worsens c BM/sitting/movement
Drainage that smells horrid
Visible inflam/palpable cord
168
Folic acid lower than __ is a deficiency. What else should you check at the same time and why?
150 ng/mL
| Check B12 too! Fixing folic acid-def will mask a B12-def.
169
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?
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.
170
What's more important to note than BMI?
Unintentional wt loss of 10% or more
171
Unfortunately, doing too many resections or having too many fistulas-and-stuff leads to __ in Crohn's pts.
Malabsorption syndromes.
172
What is pernicious anemia?
Autoantibodies against B12 and IF
173
Marasmus-like deficiency occurs in diseases like... (4)
HF, COPD, CA, AIDS
174
What are the 3 most common presenting Sx for RECTAL CA?
Hematochezia + narrowed stool + tenesmus
175
Which types of abscesses need to be drained in the OR? How?
Perirectal - intersphincteric, or supralevator stemming from pelvic infection
Through the rectum :0
176
Besides an elevated alk phos, what else helps me Dx cholestasis?
U/S to check for blockages as cause
| CT or MRI to check for liver damage as cause
177
Normal total bili is ___.
| Normal direct bili is ___.
0.3-1.9 mg/dL
| 0-0.3 mg/dL
178
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?
Hepatocellular pattern
Intrahepatic injury
(total bili does NOT have to be elevated for it to be hepatic!)
179
What are the three types of adenomatous polyps, listed from least to most scary? Which is most common?
Tubular (most common)
Tubulovillous
Villous
180
Half of all Crohn's pts have involvement in ...
Terminal ileum + ascending colon
181
Which type of hemorrhoids are viscerally innervated? As a result, what are their characteristics?
Internal
| NTTP/pain/temp
182
Age and race of UC pts? What infections are associated with triggering UC?
```
15-30 and 50-70yo Ashkenazi Jews
GI infections (campylobacter, shigella, salmonella)
```
183
Keep an eye out for _ + _ + _ which should scream "metastatic CRCa!!!!!"
Wt loss + ascites + cachexia !!
| CRaCk is WACk
184
What does a sphincterectomy remove? What is the main complication?
Lateral internal sphincter
| Can cause fecal incontinence
185
Why put in an NGT tube in a GIB pt?
To see if there is active UGIB, differentiate it from LGIB. Controversial
186
It's the usual CA workup for a confirmed anal CA Dx, aka __, __, +/- __.
CT/MRI (Abd/pelv)
PET-CT
FNA
187
What population is especially prone to cholelithiasis?
Native Americans, and Fat Fertile Forty Fair women.
188
How and in whom do we Tx cholelithiasis?
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
General Sx of LGIB? (3ish)
Blood - melena/hematochezia/BRBPR
PAINLESS BLEEDING
+/- abd pain/fullness
190
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)?
EGD q1-3yr once 20yo +
Chemoppx COX2i 400mg bid +
Ppx Colectomy +
Screen what's left q6mo-2yr
191
If a Crohn's pt is gonna get an extraintestinal manifestation, what 3ish things is it most likely to be?
Uveitis
Arthralgia
Pyoderma gangrenosum or erythema nodosum
192
Which types of abscesses can be drained outpt? How?
Perianal - ischiorectal, or supralevators that extend from ischiorectal.
I&D
193
_-sided CRCa is more common in inherited CRCa. _-sided CRCa is more common in nonhereditary CRCa. Which is more common?
Right - inherited
| Left - sporadic (75% of CRCa, so way more common)
194
What are the four chemo Rxs preferred for CRCa? (note - can do combos, they all have weird names like ~fox~ and ~ox~)
5-FU
Oxaliplatin
Irinotecan
Leucovorin
195
What is the 'best' type of polyp? What do they look like?
Mucosal (<5mm, look like surrounding tissue)
196
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 __.
8yrs
Previous CRCa (duh)
Large (>1cm) or icky (tubulovillous/villous) adenoma
black
197
Transphincteric is Parks __ and is located...
2
| Through ext sphincter to ischiorectal fossa
198
More gallstones are made of ___ than __. What is the precursor to actual stones?
Cholesterol > calcium bilirubinate pigment
| Sludge
199
Acute anal fissures are present for less than __. What are the Sx of anal fissures?
8wks
Anal pain at rest
Bleeding
(also they're visible)
200
When should we start CRCa screening in an ASx, non-risky pt?
50yo, or 45yo if they're African-American.
201
What would internal hemorrhoids look like on anoscopy?
Bulging blue-purple veins
202
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?
Fecal calprotectin (a marker of intestinal inflam)
203
The gold standard for celiac Dx is ...
Duodenal Endoscopy + Bx (no villi, hypertrophic crypts)!
204
What can you do to help ensure hernias won't recur?
Put the mesh in right and go for lap if you can.
205
Which type of hemorrhoids are painful? What are they made of?
External, especially with clots
| Squamous ep
206
The three parts of the gallbladder are the __, __, and __, and together they are responsible for...
Neck, body, fundus
| Store bile, which helps break down fat.
207
How does cholestasis present?
RUQ colicky pain
Dark urine
Jaundice
Wt loss
208
Besides the aforementioned colonoscopies, what should you do to monitor your Crohn's pt?
Screen qyr for active infections like TB/HIV/Hep etc.
209
Open, lap, __, and __ are all options for hernia surg.
Open tension-free mesh
| Open primary approximation non-mesh
210
In simplest terms, what is cholestasis?
Things aren't moving at the gallbladder (obstruction, liver damage, etc.)
211
What are the four places you can put a mesh?
Overlay - above fascia
Inlay - between fascia
Sublay - between rectus and peritoneum
Underlay - intraperitoneal
212
Indirect bilirubin is aka __, and normally is...
Unconjugated bilirubin
| What freed heme turns into, carried by proteins, to liver, small amount present in bloodstream.
213
What are the three options (and their timeline) for CRCa detection?
FIT qyr
gFOBT qyr
FecalDNA q1-3yr
214
Tx anorexia by...
Referring to psychiatrist only.
215
Most important things to note on LGIB HxPE:
HPI -
PMHx -
Rx -
HPI - Sx before? painless = div., change in bowel habits = CA, abd pain/diarrhea = colitis
PMHx - coagulopathy, diverticulosis, prior GIB
Rx - NSAIDs, anticoags, antiplts
216
2 big clinical features of anorexia?
Wt loss --> 15% below expected wt
| Amenorrhea (at least 3 cycles) - does not usually occur in bulimia
217
Protein loss starts in ___ and progresses to....?
Skeletal muscle --> liver/GI/kidney/heart/resp/B and T cells
218
Who does Lynch Syndrome present in most, and where? What is it?
~45yo men>women
R colon
polyp ---> CA much more likely!
219
FJP is usually ASx, but if it's not, what 3 Sx are most likely to present?
Painless rectal bleeding
Rectal prolapse
Failure to thrive
220
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?
Squamous (common - SCC)
Transitional (common - SCC)
Glandular (adenocarcinoma)
221
Pale conjunctiva = ___.
Chronic blood loss.
222
Who gets UGIB?
Older, men>women
223
(this is gonna be a real stretch on the way I memorize it) Which monoclonal antibody Rxs act on EGFR? VEGF?
Set the pan for an egg fry (Cet- and Pan- for EGFR)
| Bev is a vegetable (Bev- for VEGF)
224
How does pilonidal disease happen?
Opened/damaged pores become clogged with hair and debris and get infected
225
What is the main difference between primary and secondary bile acids?
Primary - made in liver
| Secondary - made in colon
226
When should we start CRCa screening in an African-American pt who is NOT high-risk?
45yo
227
Besides trauma and FamHx, risk factors for groin hernias include chronic __, chronic __, and smoking.
Cough
| Constipation
228
Repair hernias >__. At what point does repair become difficult?
2cm
| >10cm is hard to fix
229
IBD causes what type of polyp? What do they look like?
Inflammatory pseudopolyps (look like irregular islands)
230
```
Most important things to note on UGIB HxPE:
HPI -
PMHx -
Rx -
SocHx -
```
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
What am I looking for on a Crohn's Bx?
Ulcers, strictures, skip lesions!
232
Sx of VitB12-def are __ of tongue, __ neurologically, and ___ anemia.
Glossitis
Paresthesia/dementia/balance issues
Slow-onset
233
In what circumstances would we give abx to Tx pilonidal disease?
Basically, if they are at high risk for big infections.
Immunosupp, endocarditis risk, have cellulitis around it, or it's dirty
234
A Grade II internal hemorrhoid looks like...
A bulge that prolapses with straining but reduces spontaneously after
235
Your Crohn's pt gets a fistula. Assuming your Tx does not fail, how do you Tx it?
TPN + monoclonal antibody x 10wks
236
Which type of groin hernia is worse? Why?
Femoral: rarer, and can get incarcerated/strangulated
237
Besides an infected anal crypt gland, what are some etiologies of anal fistulas?
COLARR
```
Crohn's
Obstetric injury
Lymphogranuloma venereum (d/t chlamydia)
Actinomycosis
Rectal foreign body
Rectal proctitis
```
238
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?
Not risky, screen just like any random healthy dude
| But when you do get around to screening, use colonoscopy.
239
What is Parks 1?
Intersphincteric (dentate to anal verge)
240
You get a pt's labs back, and everything is normal except their total bilirubin, which is elevated. What's going on?
Isolated hyperbilirubinemia
241
Besides being villous, what characteristics of a polyp make ya antsy for CA?
Hi-grade dysplasia
| >#1 of >1cm or >#3 of any size
242
Your Crohn's pt gets a perianal fissure. How do you Tx it?
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
If a fistula is not involving the sphincter muscles, what is it called, and what Parks classification is it?
Superficial
| None
244
How should we Tx CRCa?
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
What am I looking for on a double Ba enema?
Apple-core narrowing + marked distention
246
SrFerritin
<12 ng/mL
| <30 ng/mL
247
Besides developing countries, where else might you see Kwashiorkor?
Hypermetabolic state pts - trauma, sepsis, burns
| 20% of hospitalized pts!
248
What is the gold standard for Crohn's Dx?
Colonoscopy + Bx
| note - CT might help
249
UC Dx depends on exam, colonoscopy, and histology. What would we be looking for on histology?
Crypt abscesses
| Plasma cells/eosinophils/lymphocytes
250
What are some strategies for preventing polyps?
Low-fat diet, normal BMI, dec EtOH/cigs
| ASA (or COX-2i in advanced adenomatous polyps)
251
Folic acid-def is usually d/t...
| Who is most at risk?
Lack of dietary intake
| Preg - need 5-10x normal intake!
252
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?
Perc drainage
253
Anal fissures are usually where? What are they?
Posterior midline
| Distal longitudinal anoderm tear
254
If a CRCa detection test is positive, what do you need to make sure is also on file?
A CRCa preventative screening test
255
2/3 of all colonic polyps are __ polyps. Why is that bad?
Adenomatous ==> adenocarcinoma in 7-10yrs ==> CRCa
256
If on a scope you see NO polyps or <10mm hyperplastic ones, when should you do the next scope?
10yrs later
257
What even is an indirect inguinal hernia?
Protrudes @ int inguinal ring
258
Where do UC and Crohn's each occur? What layers of the GI tract does each affect?
UC - Affects mucosa; colon and rectum.
| Crohn's - Affects everything (transmural); entire GI tract.
259
How do you Dx an anal fissure? How do you Tx it (5)?
HxPE ONLY
```
Fiber
Sitz bath
Stool softener + laxative
Topical analgesics
Topical vasodilators
```
260
When generically screening for CRCa risk, start asking about FamHx at age __ and ask again every __.
20yo
| q5-10yrs
261
Post-op anal CA pt: Get __, __, __ q3-6mo x 5yr; get __ qyr x 3yr.
DRE/Anoscopy/palp of inguinal node
| CT
262
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?
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
What 3 Rxs can cause gallstones?
Octreotide
Ceftriaxone
Clofibrate
264
How do we monitor known FJP pts?
Colonoscopy q1-3yrs starting at 15yo
265
Generally, what three things am I keeping an eye out for on exam if I suspect UC?
Abd +ttp
BRBPR on DRE
Extraintestinal stuff (like AIHA, mouth ulcers, PSC, etc.)
266
5 Screening/Dx tests for polyps? Which is best?
FOBT --> double Ba enema --> CT colonography --> Flex Sigmoidoscopy --> Colonoscopy (GOLD STANDARD)
267
AST is found in ___, is elevated ___, and normal value is _____.
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
What's important to remember when doing a physical exam on a suspected hernia pt?
For women, note that...
For men, note that...
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
What's the recommended repair for incisional hernias <2cm?
mesh repair. Required for any ventral hernia >2cm.
270
Most anal fissures are primary caused by trauma. What are 4 secondary causes?
Crohn's
CA
STIs
Granulomatous stuff (TB/sarcoid)
271
Direct bilirubin is aka ___, and normally it is...
Conjugated bilirubin
| In bile and excreted in stool, not present in bloodstream
272
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?
In 5yrs
| Ditto for nondysplasia'd small (<1cm) serrated sessile polyps.
273
You know what Murphy's sign is. What about Courvoiser's sign?
That's a palpable gallbladder d/t common bile duct obstruction.
274
Most groin hernias are located on which side? What is the usual presenting complaint?
R
| Heaviness/dull discomfort esp @ end of day/when straining + groin bulge
275
You did a scope, found a large polyp >2cm, and excised it. Now what?
F/u scope in 3-6mo!
276
How often should your CRCa (with no mets) pt get a f/u CT post-op?
qyr x 5yr
277
__ and __ hernias occur off the midline, as well as some incisional hernias.
Spigelian
| Parastromal
278
What is the most common presenting Sx for L-sided CRCa? R-sided?
L-sided: bowel changes!
| R-sided: iron-def anemia
279
3 Sx of acute cholecystitis?
RUQ pain + fever + leukocytosis
280
Muscle wasting usually first presents at __ and __.
Thenar eminence and temples.
281
UC Dx depends on exam, colonoscopy, and histology. What would we be looking for on colonoscopy?
Diffuse, friable, erosions, bleeding, ulcers
282
Two subtypes of Hamartamous Polyposis Syndromes are __ and ___. What genes are affected in each?
Familial juvenile polyposis (SMAD4/BMPR1a)
| Peutz-Jeghers Syndrome (STK11)
283
What's the name of the protocol we use to stage severity of Crohn's?
Montreal Classification (L1-4 is how much it covers; B1-3 is whether it strictures/penetrates)
284
For a polyp 5-10mm, what should we do to remove it during a colonoscopy?
Standard snare excision
285
How and where do bile salts get recycled?
In terminal ileum, they're reabsorbed and put through portal circulation back to gallbladder
286
How do we Tx Lynch Syndrome? How do we f/u?
Colectomy!
| f/u c yearly/biannual scope starting at age 20
287
A bad anal fissure should be treated by... Name four types.
```
Surg!
Fissurectomy
Anal advancement flap
Botox
Sphincterectomy
```
288
Where do we Tx anal fistulas?
Under general anesthesia in OR
289
Before any imaging, you need to get __, __, and __, and maybe put in a __.
HxPE
Labs - order CBC c diff, CMP, Coags, preg.
ECG
+/- NGT
290
What is an anal fistula? Why does it happen?
An epithelialized track across perirectal skin
| From abscess rupturing or being drained
291
Perianal and perirectal abscesses are usually d/t __.
Infected obstructed anal crypt gland
292
What would prolapsed internal hemorrhoids look like on anoscopy?
Dark pink, glistening, +/- tenderness
293
How do you Tx celiac?
Stop eating all gluten. + Vit supps and steroids for first bit.
294
Why is the double-contrast Ba enema outdated?
Can only see half of polyps even >1cm
295
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?
3 years.
| Generally >#2 but 1cm but <2 cm
296
Besides prompt drainage, what can we do to Tx abscesses? (yeah, yeah, evidence is conflicting, whatever)
Cipro + Flagyl, or Augmentin
297
The most common Sx of anal CA is ___.
Rectal bleeding!
298
Besides monitoring for extracolonic CA, what routine monitorings do PJS pts need?
Colonoscopy q2-3yrs starting at 18yo
| EGD q2-3yrs starting at age 10
299
What two red flags in the FamHx would make you consider a pt a high-risk one?
An immediate family member with CRCa/advanced adenoma Dx'd <60yo
or
2+ immediate family members with CRCa/advanced adenoma at any age.
300
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?
If they are NRAS+, it won't work. Don't bother.
301
In celiac pts, __ suggests VitA-def, __ suggests VitK-def, __ suggests Fe-def, __ suggests B12/E-def, and __ suggests Ca2+-def.
```
A: hyperkeratosis/derm herp
K: ecchymoses
Fe: cheilosis/glossitis
B12/E: periph neuropathy/ataxia
Ca2+: Chvostek/Trousseau signs
```
302
Do po Fe2+ supp unless __, ___, or __.
HD pt
GI disease that inhibits absorption
Fail po iron
303
What are some buzzwords that can help you differentiate abscess pain from other anal/rectal issues?
Constant pain not associated with BM
Pus
Fluctuance
May have fever/malaise
304
Acute cholecystitis is almost always d/t ___. When it's not, it's called __.
Gallstones.
| Acalculus cholecystitis
305
Colonic polyps are usually ASx. If they are not, what s/s should you look out for?
BRBPR
Bowel habit change
Rectal tenesmus
Signs of int obstruction/LGIB
306
What is Parks 3?
Suprasphincteric (anal crypt to ischiorectal fossa)
307
What is Mallory-Weiss Syndrome? What similarity does it have with Boerhaave Syndrome?
Nontransmural esophageal tear
| Also with vomiting; both are UGIB
308
If you see a large sessile polyp >2cm on colonoscopy, how should you remove it?
Piecemeal excision or saline-assisted endoscopic mucosal resection
309
BMR is aka __.
| What's TEF?
BEE
| TEF (thermic effect of food)
310
If you see a diminutive polyp <5mm on colonoscopy, how should you remove it?
Cold snare excision or cold Bx forceps
311
How does acute pilonidal disease present?
ASx, or pain c sitting, drainage, tender/red mass
| +/- fever if unTx'd
312
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?
Cholestatic pattern
| Could be biliary obstruction (which is extrahepatic), or primary biliary cholangitis (which is intrahepatic).
313
Your Crohn's pt gets a perianal abscess. How do you Tx it?
CT, then broad-spectrum ABx, then perc drainage or surg.
314
What four criteria are necessary for FJP Dx?
FamHx
+ Genetic test
>#5 juvenile polyps
In multiple places of GI tract (including colon)
315
Complications of bulimia? (5)
```
Poor dentition
Electrolyte abnormalities
Gastric dilation
Constipation
Pancreatitis
```
316
How do you decide how to Tx a hernia?
Based on timeline of Sx.
<6hr = it's a strangulation => Surg
Anything later = uncomplicated fem/inguinal => elective surg (or truss in men)
317
'Diffuse inflammation' makes you think what type of IBD? Where is the other one's inflammation?
UC is diffuse.
| Crohn's is skip lesions, not diffuse.
318
How do we treat Grade I-II internal hemorrhoids?
Sclerotherapy
319
How often should your CRCa (who also had mets removed) pt get a f/u CT post-op?
q3-6mo x 2yr (conveniently the same as your physical exam f/u)
then
q6mo x 5yr
320
What's important to know about B12-def replacement?
Must be monthly for a lifetime.
321
When Dx'ing celiac, which Ig is important to get?
IgA! antibodies or def = likely
322
What makes up the common bile duct?
Cystic duct + hepatic duct
323
Gastric vs duodenal ulcers
Gnawing/burning pain is shortly after meals for gastric, 2-3hr later for duodenal.
Gastric is more common in PUD.
324
We know cholangitis is pretty serious stuff. What lab values are wack? What Rxs should you start right away?
WBCs elevated
| so... hang IV cipro + flagyl, or gentamicin + ampicillin
325
You started your cholangitis pt's IV abx. Now what?
ERCP stat, they'll send them for lap chole soon after.
326
PSC is a very rare, diffuse inflam/fibrosis/stricture of the entire biliary system. Who gets it?
```
UC PATIENTS (and some Crohn's ones, and if certain PSC genes run in the family)
20-50yo men > women
```
327
Sx of PSC include fatigue, indigestion, __, __, and __.
Anorexia, Pruritis, Progressive obstructive jaundice
328
What two labs will for sure be off in PSC? Why?
```
Alk Phos high (because this is biliary)
Albumin low (no protein from diet because of malabsorption)
```
329
Besides checking genetic/autoimmune stuff, how do we Dx PSC? (3)
ERCP
MRI
Liver Bx
330
What will a PSC liver Bx look like?
'onion skinning'
331
Most important complication of PSC to note?
Cholangiocarcinoma!
332
PSC will kill your pt in about 15 yrs. In the meantime, how do you Tx it if acute? If chronic?
Acute - cipro
| Chronic - dilation/stent, or resecting any strictures
333
How do your Tx plans change if someone's got PSC AND cirrhosis?
Liver transplant is your only option.
334
What prevents doudenal juices from refluxing back up into the ducts?
Sphincter of Oddi
335
What 3 hormones are released by the pancreas?
Insulin, Glucagon, SST
336
The most common cause of chronic pancreatitis is...
EtOH!
337
The most common causes of acute pancreatitis are.... (10)
```
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
The most life-threatening complication of acute pancreatitis is ___, such as __ and __.
Multisystem organ failure: renal failure, ARDS (think: pancreas is right by lungs/diaphragm!!)
339
Pancreatic necrosis is a complication of ___ and requires what kind of Tx?
Acute pancreatitis
| Perc drainage +/- abx
340
Acute pancreatitis (not the severe cases, just in general) present as...
N&V, epigastric pain maybe rad to back, with relief upon tripoding; jaundice
341
Severe acute pancreatitis presents as... (5ish)
Grey-Turner and Cullen's signs
Tachypnea
Hypoxemia
Hypotn
342
What is Grey-Turner sign? Cullen's sign?
G-T - Flank ecchymosis
| Cullen - Periumbilical ecchymosis
343
What lab values are likely to be high in acute pancreatitis? Are those also high in chronic pancreatitis?
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
Dx of acute pancreatitis requires 2 or more of the following:
Classic pain presentation
Lipase and/or amylase >3x ULN
Contrast CT confirmation
345
You Dx a pt with acute pancreatitis. Now what?
Admit them, IVF/NPO/analgesic/antiemetic. Figure out cause. Serial labs to watch for renal failure or fluid overload.
346
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.
Systemic Inflam Response Syndrome Score: How severe is the pancreatitis?
- high or low body temp
- tachycardia
- tachypnea
- some lab value stuff
347
The Atlanta Classification for acute pancreatitis, in a nutshell, says it's mild if __, moderate if __, and severe if __.
```
Mild = no organ failure
Moderate = transient organ failure, <48hr
Severe = persistent organ failure, >48hr
```
348
Holla at me with three big complications of chronic pancreatitis.
DM
CA
Becoming a drug addict
349
Order ___ to confirm Dx of chronic pancreatitis.
Abd CT!
350
Tx chronic pancreatitis with lifestyle changes, __ for steatorrhea, ___ for stones/pseudocysts/strictures, or ___ for major fix.
Pancreatic enzyme
Endoscopy
Whipple/total pancreatectomy/islet cell transplant
351
Diverticulosis occurs mostly in the __ colon and in ___ pt popn.
Sigmoid
| Old, Western-diet-eating
352
Dx diverticulousis with __.
| Dx diverticulitis with __.
A colonoscopy!!!
| Abd/pelv CT with IV contrast +/- po contrast!
353
Describe the abd pain and tenderness associated with diverticulitis.
LLQ
| Constant pain over several days with abd rigidity and rebound tenderness
354
Besides imaging, what should you order when working up a suspected diverticulitis pt?
Labs! CBC with diff, BMP, U/A.
355
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?
- Abscess (IR drain)
- Bad obstruction (urg or emerg surg)
- Free perf (emerg surg)
356
Non-surg, admitted acute diverticulitis pts get __ for the infection, __/__/__, and put NPO.
abx- Cipro (or CPN) + Flagyl is as always a good choice; could do augmentin, ertapenem, or Zosyn.
IVF/IV analgesic/IV antiemetic
357
Classify diverticulitis based on the __ System. What are your surgical options?
Hinchey
One-step: colon resection + primary anastomosis.
Two-step: those, but separately and with some -stomy's.
358
For a new diverticulitis Dx, schedule a f/u colonoscopy in ___ unless...
Why?
6wks, unless they had one within the last yr
| r/o CRCa and monitor diverticula
359
The main source of diverticular bleeds is...
R colonic diverticula
360
Diverticular bleed pts' labs might have __ H/H, but should have normal...
Low
| Normal BUN:Cr and MCV!
361
Surprise, get a colonoscopy to Dx diverticular bleeds. What are two other options?
Nuclear scintigraphy or angiography
362
How do I stop a diverticular bleed?
It should stop itself.
363
What if the diverticular bleed does not stop itself?
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
The appendix is a __ ___.
True diverticulum.
365
Who gets appendicitis?
Men > women (but both), ~10-20yo
366
Appendicitis is usually from an obstruction. When that obstruction is caused by bacteria overload, which bacteria are usually responsible? (4, think GI)
Pseudomonas
E. coli
B. fragilis
Peptostrep
367
Briefly describe the progression of appendicitis pain and Sx.
Periumbilical colicky pain --> one vomit --> RLQ dull constant pain
(with nausea and anorexia the whole time)
368
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?
CBC with diff, electrolytes, LFTs, U/A
AbdXR (free air near appendix, appendicolith); U/S, CT
369
Tx appendicitis with an appy (duh) - open or lap. How do you prep them in the meantime?
NPO
IVF/IV abx (3rd-CPN or gentamicin + Flagyl)
Call OR to let them know
370
In what three situations would we NOT do an appy?
P-lease don't operate if:
- Peritonitis
- Presence of appendix mass
- Problem fixed itself
371
The 'midgut' (sm int, __, and __) gets supplied by which artery?
sm int + ascending colon + first 2/3 transverse colon
SMA
372
Two key features of SBO on exam are...
Distention
| Tinkly sound
373
Two key features of small bowel perf/ischemia on exam are...
Fever
| Peritonitis
374
The overall most common cause of SBO is __. What about in the Western world?
Overall - post-op adhesions
| USA - hernias
375
SBOs can be __, __, or __.
Intraluminal, intramural, extramural
376
Name two examples of extramural lesions that cause SBO.
Hernias and adhesions
377
Name four examples of intramural lesions that cause SBO.
That's structural stuff- like volvulus/intussusception, or Crohn's/stricture.
378
Name four examples of intraluminal lesions that cause SBO.
That's actual objects- like bezoars, parasites, foreign bodies, or stones.
379
What happens above and below the SBO in a simple SBO?
Above - flaccidity
| Below - rigidity
380
SBOs can be simple, __, or __.
Closed-loop
| Strangulated
381
While your imaging of choice for SBO is an abd XR, what situations might make CT be a good choice?
- if SBO is d/t adhesions, it'll fix it.
| - can confirm if pt is complicated enough to need surg.
382
What can a CBC tell you in an SBO case?
Inc WBC --> think ischemia. Get to surg!
| Dec MCV/Hgb --> think CA obstruction
383
What can a Chem-7 tell you in an SBO case?
Electrolyte/renal failure
LFTs might inc
Amylase - a lot of the stuff that causes SBO can also cause pancreatitis
384
What can an ABG tell you in an SBO case?
Metabolic acidosis can happen late-stage if their int is ischemic
385
Your SBO pt has a normal set of labs except-- oh no, their lactate level is elevated!
Don't care.
386
__, __, and __ will get me to throw my pt in surg's direction faster than Brady can find Gronk in the red zone.
Irreducible hernia
Perf
Suspected strangulation/ischemia
387
Assuming my SBO pt's surg is NOT urgent/emergent, what should I do to prep them for the OR?
NPO
IVF with Is&Os (no abx)
NGT to stomach only
388
Lap surg sounds good for SBO pts. Except for which four types of pts...?
No surg AT ALL for:
- already post-ops
- recurrent SBO
- post-rad
- carcinomatosis pts (rare peritoneal CA)
389
Post-op paralytic ileus is basically gastroparesis for the small bowel. What do you do if your pt gets it?
Watch and wait, Tx any electrolyte/acid-base issues
D/c opioids
NGT PRN to decompress abd
390
Mesenteric ischemia is d/t...
| Ischemic colon is d/t...
SMA or SMV occlusion/thrombosis
| Idiopathic
391
SMA occlusion could be the result of an embolism (d/t __, __, etc) or a thrombus (d/t __, etc)
MI, AFib
| Atherosclerosis
392
NOMI (____) is d/t __ + ___ + __.
Nonocclusive Mesenteric Ischemia
| athero + shock + vasopressor
393
The big Sx of mesenteric ischemia on exam is:
Acute/constant periumbilical PAIN OUT OF PROPORTION
394
For mesenteric ischemia, you want __ and __ for labs, and what for imaging?
CBC and Chem-12
| Mesenteric angio, ideally.
395
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?
XR - thick and thumbprinted
| CT - thick, dilated, hematoma, pneumatosis
396
Tx mesenteric ISCHEMIA (not infarct) with __, __, and __!
IVF/PRBC
Anticoags
Glucagon or other vasodil
397
Your pt with confirmed mesenteric ischemia suddenly gets a fever, and peritoneal signs. What happened? What do you do?
That's an infarct, sir!
| Emerg lap surg!! + vasodil and f/u surg tomorrow
398
Ischemic colitis usually occurs in who and where?
Old people! L colon.
399
Give me like 4 reasons why ischemic colitis happens.
MVT
AFib
Hypotn
s/p AAA or MI
400
What are the 'watershed areas'?
Splenic flexure + rectosig junction
401
The physical exam for ischemic colitis is pretty nonspecific... what labs might help Dx?
Stool Cx
ABG- metabolic acidosis
CBC - WBC >20,000
402
The physical exam for ischemic colitis is pretty nonspecific... what imaging might help Dx?
```
AbdXR
Contrast CT (thick, seg, strands; gas in veins later on)
Endoscopy
```
403
Tx for ischemic colitis is supportive (eg __, __, __) unless it gets bad, then do a lap resection.
IVF, abx, NGT if ileus.
404
Most common cause of toxic megacolon is ___! Could also be viral (like __), parasitic (like __), or bacterial, like...
Crohn's and UC!
CMV colitis
Cryptosporidium
C. Diff! Salmonella/shigella, campylobacter
405
Toxic megacolon visible Sx are __ and __.
Distention and Diarrhea.
406
What do you NEED to Dx toxic megacolon?
IMAGING EVIDENCE + THREE OR MORE OF:
- Fever
- Tachycardia
- Anemia
- WBC >10,500
+ one or more of: AMS, hypotn, dehydration, electrolyte issue.
407
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.
```
IVF
IV abx if C.diff- Vanco po + Flagyl
IV steroids if IBD
NPO
NGT or nah.
```
408
Pancreatic CA usually occurs in who?
Men>women (but both) >45yo who smoke, have DM, have chronic pancreatitis, or a FamHx.
409
Your pt comes in with unintentional wt loss, new DM, and jaundice. What are you thinking?
Pancreatic CA in the head of the pancreas
410
Your pt comes in with unintentional wt loss, new DM, and epigastric pain. What are you thinking?
Pancreatic CA in the body or tail
411
If you suspect late-stage pancreatic CA, what three things do you expect might be abnormal on your physical exam?
Ascites
Palpable mass
Courvoisier's sign
412
What is Courvoisier's sign?
You can palp a GB but its nTTP. Oh, and your pt is yellow.
413
What two labs would you loveee to get to support your Dx of pancreatic CA? What about imaging studies?
LFTs and a CA 19-9
| Let's do a CT, U/S (either endoscopic or nah), and maybe an MRI.
414
Your choices for pancreatic CA Tx include...
Just surg. Nothing else. But, you do have options there!:
In the head? --> Whipple!
In the body/tail? --> distal pancreatectomy.
415
Most pancreatic CA is ___ tumors in the ___ of the pancreas.
Ductal adenocarcinoma
| Head/neck only
416
In order of most to least likely, what four places does pancreatic CA love to metastasize to?
Liver
Peritoneum
Lung
Adrenals
417
Good news for your pt-- the pancreatic tumor you Bx'd came back as ___, the benign kind.
Serous cystadenoma woot woot!
418
__ and __ are premalignant pancreatic tumors.
IPMN and mucinous cystadenomas
419
Most cases of viral diarrhea are __.
| Most cases of bacterial diarrhea are __.
Norovirus
| Campylobacter
420
Most cases of diarrhea are infectious.
Most cases of infectious diarrhea are ___.
Most cases of severe diarrhea are ___.
Viral
| Bacterial
421
Persistent and chronic diarrhea is most likely...
Non-infectious
422
Name the four virus families that cause infectious diarrhea.
Norovirus!
Astrovirus
Rotavirus
Adenovirus
423
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?
(Rice) watery, lots of it, no fever - enterotoxic
| Bloody/mucoid, little bit of it, fever - invasive
424
Enterotoxic diarrhea includes bacterial causes like __, ___ and __, and parasites like __.
C. diff/E. coli/Cholera
| Giardia
425
N/V/D within 6 hrs of eating shellfish (etc) suggests __ or __ is to blame.
S. aureus, B. cereus
426
N/V/D within 8-16 hrs of eating shellfish (etc) suggests __ is to blame.
C. perfringens
427
>16 post-ingestion of bad food, N/V/D suggests...
| Vomiting means __ usually.
other viral or bacterial infection
Vomiting means Viral!
428
Diarrhea that presents after a petting zoo visit makes you suspect...
Salmonella
429
Infectious diarrhea is your guess for Dx. What labs do you want?
C&S (for bacteria)
C. diff tox (if suspected)
O&P if parasite (if giardia suspected, etc)
Fecal leukocytes
430
What is better than fecal leukocytes but expensive AF?
Fecal lactoferrin
431
Your first Tx priority in diarrhea is...
IVF and electrolytes! Or ORS!
432
We don't want diarrhea pts to eat anything, right?
No. BRAT diet (bananas, rice, applesauce, toast)
433
Norovirus Sx are ___, ___, and ___. They start after about ___hrs. Something about cruise ships. Sx stop after...
Acute-onset N&V, watery diarrhea, abd cramps
12-48hrs
24-72hrs
434
Which four abx cause C. diff???
Clinda!
Fluoroquinolones
PCNs
CPNs
435
What abx Tx C. diff??
Flagyl q8hr or Vanco po!
436
Campylobacter comes from ___, Sx are __ and __, and it is invasive. How do we Dx it?
Undercooked meat
Abrupt-onset abd pain and bloody diarrhea
Stool Cx - because it looks like appendicitis.
437
Are salmonella and shigella enterotoxic or invasive? What does their diarrhea look like?
Invasive! = bloody diarrhea! (pea soup for salmon)
438
What is important to note about the Tx of shigella and E. coli?
Hemolytic-Uremic Syndrome (ARF, Hemolytic Anemia, Thrombocytopenia) = NO ABX!!!
439
How is shigella spread? How do we Dx it?
Fecal-oral (esp. those into anal sex)
| Stool Cx
440
What scrip do you give to someone who wants to prevent traveler's diarrhea?
ppx Cipro (anti-shigella, anti-E. coli which is most common cause)
441
Describe the diarrhea of cholera. Why is it so scary? How do we Tx it?
Massive rice-watery
Hypovolemic shock within 24hr
Tx- IVF + abx
442
Intestinal entamoeba: invasive or enterotoxic? What are its Sx?
```
Starts infective (cyst form) --> invasive (trophozoite form)
Invasive! = bloody diarrhea. Scary version --> fulminant colitis.
```
443
Who gets intestinal entamoeba? How do we Dx and Tx it?
Nursing home/prisoners
O&P + SrAntigen
Flagyl!
444
The most common cause of foodborne diarrhea in the US is __. How do we Tx it?
Cryptosporidium
| Nitazoxanide (good Nite parasite)
445
Giardia diarrhea is special because...
| We Tx it with __, but...
It's yellow and smells GROSS
| Flagyl or Nitazoxanide (good Nite parasite), but Sx last up to 6wks more
446
Noninfectious causes of diarrhea include __, __, and __ in old pts.
IBD, IBS, and fecal impaction
447
How often do you have to have IBS Sx for it to count?
At least 1 day per week in last three months
448
We Tx IBS with lifestyle changes. But what Rxs can we add for IBS-C?
PEG, Lubiprostone, Linaclotide
449
Steatorrhea indicates ___.
MALABSORPTION.
450
Gold standard test for malabsorption is __.
Quantitative Stool Fat Test!
451
po > IV for diarrhea Tx, so shotgunning a Gatorade is as good as an IV NS bag, right?
Gatorade is a lie.
| But po > IV is not.
452
Why is water not a good ORS?
Diseased sm int will NOT absorb water without salt or sugar to transport it!
453
What's my IVF target for a severely dehydrated pt?
200mL/kg body weight of oral or IV fluid replacement in 24 hours... yikes
454
Loperamide is NOT INDICATED if...
It's a bacterial diarrhea - we want to get that stuff out!
