GI/Nutrition Flashcards
What other compounds are elevated in folate and B12 deficiencies, respectively?
Homocysteine is elevated in both (and in B6 deficiency)
MMA (methylmalonic acid) is elevated only in B12 deficiency
Symptoms of niacin deficiency?
Pellagra: diarrhea, dermatitis, dementia
dermatitis: rough, dark, scaly skin in sun-exposed area
Classic presentation of carcinoid syndrome
Diarrhea, episodic flushing, venous telangiectasias, right heart valve disease
Cardiac involvement in carcinoid syndrome
TIPS: tricuspic insufficiency, pulmonic stenosis (due to steroid-induced fibrosis of valves)
Serum marker for carcinoid syndrome
5-HIAA (5-hydroxyindoloacetic acid), a serotonin metabolite
Giardia: test? Treatment?
Test: stool antigen assay
Treatment: Metronidazole
Neck mass that increases with drinking: diagnosis? test?
Zenker diverticulum.
Test: contrast esophagram
Difficulty initiating swallow: diagnosis? test?
Oropharyngeal dysphagia.
Tetst: videofluoroscopid modified barium swallow
Initial test for esophageal dysphagia that begins with liquids and solids?
For esophageal dysphagia that progresses from solids to liquids?
If starts with solids and liquids together, perform barium swallow first (likely a motility defect, e.g. achalasia)
If begins with solids only, perform endoscopy first (likely mechanical obstruction, e.g. stricture or cancer).
Risk factors for esophageal adenocarcinoma? SCC?
Adenocarcinoma: GERD (Barrett’s), smoking
SCC: Alcohol abuse, smoking
Brief episodes of non-cardiac chest pain with dysphagia during the episode only. Diagnosis? Best test? Initial treatment?
Diagnosis: Diffuse esophageal spasm
Test: manometry
Treatment: CCBs (diltiazem)
Diagnostic test for suspected esophageal perforation
Water-soluble contrast esophagram or CT
Do not due barium swallow
Initial treatment for low-grade MALT lymphoma due to H. pylori?
Second-line treatment?
Initial treatment: Triple therapy for H. pylori (PPI, clarithromycin, amoxicillin)
Second-line: chemotherapy
Pattern of markers in hepatitis B infection that clears
- Surface antigen appears
- IgM against core antigen
- Surface antigen disappears (window period)
- IgM against surface antigen
Three extrahepatic manifestations of hepatitis C
- Porphyria cutanea tarda (blistering 2-3 days after sun exposure, reddish urine due to porphyrins)
- Membranoproliferative GN (and so HTN)
- Mixed cryoglobulinemia (fatigue, arthralgias, palpable purpura, low C4, positive RF)
Labs in mixed cryoglobulinemia
- Low complement, especially C4
- Positive rheumatoid factor
- Cryoglobulins
Labs in cholestasis
Elevated alk phos and blirubin, only mild elevation in AST/ALT
Presentation of Wilson’s disease (3)
- Chronic hepatitis / cirrhosis
- Neurological signs: tremor, rigidity, ataxia, slurred speech, depression
- Kayser-Fleisher rings
Labs in shock liver
Dramatic AST/ALT elevations, mild elevations in alk phos and bilirubin
Patient with cirrhosis and ascites comes in with fever or AMS: required test?
Diagnostic paracentesis (to check for SBP)
Empiric treatment of SBP
3rd-generation cephalosporin (cover gut flora like E. coli and Klebsiella)
Right-sided pleural effusion in a patient with cirrhosis: likely diagnosis?
Hepatic hydrothorax (ascitic fluid passes through small holes in diaphragm into the pleural space)
New-onset ascites: diagnostic test?
Paracentesis
Interventional prophylaxis for esophageal varices in cirrhosis? Medical prophylaxis?
Interventional: band ligation
Medical: nonselective beta-blockers like propanolol or nadolol (reduce portal blood flow)
Screening for HCC in cirrhotics?
Screening US every 6 months
Initial treatment for bleeding esophagael varices?
Next step?
Initial treatment: Volume rescusitation via 2 large bore IVs, prophylactic antibiotics, octreotide
Next stop: endoscopy within 12 hours
Labs in hepatorenal syndrome
Similar to pre-renal azotemia (low urine sodium, elevated BUN/Cr), unremarkable urine sediment.
(A result of renal vasoconstriction)
Endocrine abnormality in cirrhosis leading to spider angiomas, palmar erythema, gynecomastia, testicular atrophy?
Hyperestrinism (due to decreased estrogen metabolism)
Thyroid labs in cirrhosis?
Low total T3 and T4, but normal free T3, free T4, and TSH
Due to decreased thyroid hormone carrier proteins
Treatments for hepatic encephalopathy (2)
- Lactulose (acidifies colon, converts NH3 to NH4+ which is trapped in lumen)
- Rifaximin (kills gut flora that make ammonia)
Tumor marker for HCC
Alpha-fetoprotein
Liver mass in association with long-term OCP use:
Diagnosis? Test? Treatment?
Diagnosis: hepatic adenoma (usually benign)
Test: US and then CT (do not perform needle biopsy, risk of bleeding)
Treatment: surgical excision
Triad for acute cholangitis? Pentad for severe disease?
Charcot’s triad: fever, jaundice, RUQ pain
Reynold’s pentad: add confusion and hypotension
Primary biliary cirrhosis and primary sclerosis cholangitis: which is seen more in men, and which in women
PBC: women (9:1)
PSC: men (2-3:1)
Antibody associated with primary biliary cirrhosis?
Anti-mitochondrial antibodies
Treatment for primary biliary cirrhosis?
Ursodeoxycholic acid
What disease is primary sclerosing cholangitis strongly associated with?
Ulcerative colitis
General treatment for acute pancreatitis?
NPO, IV fluids, pain control
Generally do NOT give prophylactic antibiotics, unless there is e.g. evidence of necrotizing pancreatitis on CT scan
Initial test for gallstone pancreatitis? Treatment?
Initial test: US (better than CT)
Treatment: NPO, IV fluids, pain control, then ERCP to remove stone
Drugs associated with drug-induced pancreatitis? (5)
- Valproic acid
- Azathioprine (AZA) and its metabolite, 6-mercaptopurine (6-MP)
- Mesalamine / 5-ASA
- ACEIs
- Statins
Possible exam finding in pancreatic cancer
Virchow’s node: left supraclavicular adenopathy
Most common cause of upper GI bleeding?
PUD
Pattern of gastric and duodenal ulcers with respect to meals?
Gastric: worse during meal (acid secretion, movement during meal)
Duodenal: worse 2-3 hours after (food buffer has left unapposed acid behind), often wakes up at night
Treatment for H. pylori associated PUD?
Triple therapy: PPI, clarithrmycin, and amoxicillin
Initial test for small intestine bacterial overgrowth (SIBO)? Gold standard for diagnosis?
Initial test: hydrogen breath test using lactulose (see early peak as lactulose metabolized in small bowel)
Gold standard: endoscopy, jejunal aspirate with >10^5 organisms / mL
Initial test to differentiate between causes of malabsorption? Follow-up test if abnormal?
Interpretation?
Initial test: D-xylose urinary excretion test (absorbed from small bowel without requiring enzymes and excreted in urine)
F/u test if abnormal: rifaximin then repeat
In enzymatic deficiency (e.g. pancreatic insufficiency), will be normal.
In mucosal disease (e.g. celiac), will have low excretion that persists after rifaximin
In small intestinal bowel overgrowth, will have low excretion due to breakdown by bacteria, but will normalize after rifaximin
Labs in Zollinger-Ellison syndrome
Markedly elevated serum gastrin (>1000 pg/ml) despite acidic gastric pH (<4)
(Note that lack of stomach acid (e.g. 2/2 PPI) can lead to elevated gastrin, so need to check gastric pH)
Febrile diarrhea associated with extra-GI symptoms with small bowel biopsy showing villous atrophy and PAS-positive materials: diagnosis? cause?
Whipple’s disease, infection with Tropheryma whipplei
Test for acute diverticulitis
CT scan (due NOT scope during acute infection due to risk of perforation)
Most common cause of colovesical fistula? Two other causes?
Most common: diverticulitis
Others: Crohn’s disease, colon cancer
(But NOT UC, since it is not transmural)
Other conditions associated with angiodysplasia in the colon (3)
- Renal disease (more likely to bleed)
- vW disease (more likely to bleed)
- Aortic stenosis (disrupts vWF and may make more likely to bleed)
Dark brown pigmentation in proximal colon: name? likely cause?
Name: melanosis coli
Likely cause: laxative abuse
Pathologic hallmark of ulcerative colitis
Crypt abscess
Causes of toxic megacolon (5)
- Infection (e.g. C. diff, or CMV in AIDS)
- IBD
- Ischemic colitis
- Volvulus
- Obstructive colon cancer (less common)
Treatment for toxic megacolon due to IBD? Due to other causes?
IBD: Antibiotics, NPO, IVF, plus IV corticosteroids
Other causes: the same but no steroids
Surgery may be required
Treatment for mild/moderate C. diff? Severe?
Mild/moderate: oral metronidazole
Severe: oral vancomycin (+/- IV metronidazole)
3 types of polyps that may be seen on colonoscopy
- Adenomas
- Hyperplastic (benign, nothing needed)
- Hamartomatous polyps (juvenile polyp, Peutz-Jegher polyps - not pre-malignant, but removed due to bleeding risk)
Colon adenoma pathology that is more likely to become malignant? Shape?
Villous pathology more pre-malignant than tubular
Sessile more pre-melignant than pedunculated
Cancers seen in Lynch syndrome?
- Colon cancer (HNPCC)
- Ovarian cancer
- Endometrial cancer
Serologic marker in autoimmune hepatitis
Anti-smooth muscle antibody
Normal liver span
6-12 cm
Common bacterial causes of bloody diarrhea
Enereohemorrhagic E. coli, Camyplobacter, Shigella
Watery diarrhea associated with rice
Bacillus cereus food poisoning
Difference in presentations between Bacillus cereus and Staph aureus food poisoning
B. cereus: mainly watery diarrhea, vomiting rare.
Staph aureus: mainly vomiting, although diarrhea may also be seen
Brief watery diarrhea with fever associated with unrefrigerated food
Clostridium perfingens
Diarrhea associated with raw or undercooked shellfish
Vibrio vulnificus (can lead to invasive disease in immunocompromised and liver disease)
Diarrhea that can lead to hemolytic uremic syndrome
Enterohemorrhagic E. coli
Bacterial diarrhea that can cause invasive, life-threatening illness in the immunocompromised or thsoe with liver disease
Vibrio vulnificus (associated with undercooked shellfish)
Groups of adults that should receive hepatitis A vaccine
- Chronic liver disease
- Travelers to endemic areas
- Men who have sex with men
- IV drug users
Treatment for CACS (cancer-related anorexia/cachexia syndrome)
Progesterone analogs, e.g. megestrol acetate
Corticosteroids can also be used but have more side effects
Causes of elevated homocysteine
Deficiency of folate, B12, and B6
