GI & Rheuma/Immuno Flashcards
1
Q
Most common causes of indigestion (2)
A
GERD
Functional dyspepsia
2
Q
Next best step after diagnosing GERD?
A
Start PPI (typical GERD does not need further work up)
3
Q
Most severe histologic consequence of GERD and a major risk factor for adenocarcinoma
A
Barrett’s epithelium
4
Q
When is upper endoscopy the recommended INITIAL TEST in GERD?
A
- In unexplained dyspepsia in >55 years old
- (+) alarm factors: dysphagia, weight loss, anemia, bleeding
*R/O malignancy
5
Q
Classic symptoms of GERD
A
- Water brash
- Substernal heartburn
6
Q
Most sensitive test for diagnosis of GERD
A
24-h ambulatory pH monitoring
7
Q
Gold standard for confirmation of Barret’s esophagus
A
Endoscopic biopsy
8
Q
Useful initial diagnostic test when mechanical obstruction of esophagus is suspected
A
Endoscopy
9
Q
Most common esophageal symptom of GERD
A
Heartburn/pyrosis
10
Q
Most common cause of esophageal chest pain
A
GERD
11
Q
Characteristic symptom of infectious esophagitis
A
Odynophagia
12
Q
Most common cause of acute diarrhea
A
> 90% are infectious
13
Q
Most common noninfectious cause of acute diarrhea
A
side effect of medications
14
Q
Major cause of death in acute diarrhea
A
dehydration
15
Q
When to give antimotility/antisecretory agents in diarrhea?
A
Moderate/severe nonfebrile and nonbloody diarrhea
16
Q
Complications of PUD
A
- Bleeding
- Perforation
- Gastric outlet obstruction
17
Q
First line treatment for H. pylori
A
- Triple Therapy (“OCA”): Omeprazole + Clarithromycin + Amoxicillin
- Quadruple (“TOMB”): Tetracycline + Omeprazole + Metronidazole + Bismuth
18
Q
Has a central role in gastric epithelial defense/repair
A
Prostaglandin
19
Q
Key enzyme that controls the rate-limiting step in prostaglandin synthesis
A
Cyclooxygenase
20
Q
Duodenal ulcers occur most often in which part of the duodenum?
A
1st part of duodenum (>95%)
21
Q
2 predominant causes of PUD
A
- NSAID ingestion
- H. pylori
22
Q
Benign gastric ulcers are most commonly found where?
A
distal to the junction of the antrum and the acid-secreting mucosa
23
Q
Most discriminating symptom in duodenal ulcer
A
pain that wakens the patient from sleep (between 12AM to 3AM)
24
Q
Most frequent finding in gastric ulcer or duodenal ulcer
A
epigastric tenderness
25
Mainstay of PUD treatment (goals of treatment)
- eradication of H. pylori
| - prevention of NSAID-induced disease
26
Most potent acid inhibitory agents available
protom pump (H+,K+-ATP-ase) inhibitors
27
Upon diagnosing a case of acute pancreatitis, what is the next best step to confirm this diagnosis?
serum lipase
28
Best diagnostic work-up for abdominal ecchymosis?
abdominal CT scan with IV contrast
29
Cardinal symptom of pancreatitis
Abdominal pain, often in upper abdomen, with radiation to the back
30
Leading cause of acute pancreatitis
Gallstone
31
2nd most common cause of acute pancreatitis
Alcohol
32
Periumbilical ecchymosis
Cullen's sign
33
Flank ecchymosis
Grey Turner's sign
34
Criteria for diagnosing acute pancreatitis
The diagnosis of acute pancreatitis is established by 2 out of 3 of the ff:
1. typical abdominal pain in the epigastrium that may radiate to the back
2. three-fold or greater elevation in the serum lipase and/or amylase
3. confirmatory findings of acute pancreatitis on cross-sectional abdominal imaging
35
Why is serum lipase a more reliable marker for pancreatitis than serum amylase?
Lipase is more specific to pancreas and remains elevated longer
36
Early vs late pancreatitis
Early: <2 weeks
Late: >2 weeks
37
Mild vs moderate vs severe pancreatitis
Mild: no organ failure
Moderate: transient (<48h) organ failure
Severe: persistent (>48h) organ failure
38
Most common cause of death in acute pancreatitis
Hypovolemic shock
39
Most important intervention in acute pancreatitis
Safe, aggressive IV resuscitation
40
Supportive managment for acute pancreatitis
1. NPO (bowel rest)
2. IV fluids (to avoid hemoconcentration)
3. Pain control (Meperidine)
41
Level of hypertriglyceridemia that may cause pancreatitis
>1000 mg/dl
42
Charcot's triad of cholangitis
"FPJ":
1. fever
2. pain
3. jaundice
43
Management for gallstone pancreatitis
ERCP within 24-48 hours (for those with evidence of ascending cholangitis)
44
Melena indicates blood present in GIT for how long?
at least 14 hours and as long as 3-5 days
45
Most common cause of UGIB
Peptic ulcers
Others: variceal bleed, Mallory-Weiss tear
46
Most common cause of LGIB
Hemorrhoids
Others: Diverticular disease, colonic mass, angioectasia, colitis
47
Which promotility agent is given prior to endoscopy to improve endoscopic visualization?
Erythromycin 250mg IV, 30 mins prior to procedure
48
When to transfuse blood in a patient with active GI bleeding?
When Hgb <7 g/dl
49
When will a change in Hgb be observed after initial GI bleeding event?
Up to 72 hours after initial bleeding evente
50
When to do upper endoscopy in LGIB?
For active hemorrhage/hemodynamic instability (to R/O UGIB)
51
Classic history of Mallory-Weiss tear
vomiting, retching, coughing preceding hematemesis
52
Endoscopic therapy of choice for esophageal varices
Ligation
53
Responsible for majority of cases of obscure GIB
small intestinal sources of bleeding
54
Most common cause of obscure GIB in adults
vascular ectasias, tumors, NSAIDs
<50 yo: small bowel tumors
>50 yo:: vascular ectasia, NSAIDs
55
Most common cause of significant LGIB in children
Meckel's Diverticulum
56
Most common colonic cause of LGIB in children and adolescents
IBD and juvenile polyps
57
Test of choice of GI bleed
UGIB: upper endoscopy
LGIB: colonoscopy (unless with massive bleed)
Massive obscure bleed: angiography
58
Serum bilirubin level in scleral ictus
>3 mg/dl
59
Liver disease pattern wherein ALT/AST > ALP
Hepatocellular pattern
60
Liver disease pattern wherein ALT/AST < ALP
Cholestatic pattern
61
Most common and most characteristic symptom of liver disease
Fatigue (typically occurs after activity, afternoon fatigue)
62
Hallmark symptom of liver disease and most reliable marker of severity
Jaundice
63
Cause of RUQ pain in liver disease
Stretching or irritation of Glisson's capsule
64
Single most common risk factor for Hep C
injection drug use
65
Liver diseases with AST/ALT >1000 U/L
- viral hepatitis
- ischemic liver injury
- toxin- or drug-induced liver injury
66
Gold standard in diagnosing most liver diseases
Liver biopsy
67
AST:ALT >2 is seen in what condition?
alcoholic liver disease (AST > ALT)
68
AST:ALT <1 is seen in what condition?
chronic viral hepatitis, nonalcoholic fatty liver disease (AST < ALT)
69
Prodromal phase precedes onset of jaundice by how long?
Prodromal phase precedes onset of jaundice by 1-2 weeks.
With onset of jaundice, constitutional symptoms disappear
70
When does complete clinical and biochemical recovery in viral hepatitis occur?
For HAV & HEV: 1-2 months after onset
| For HBV & HCV: 3-4 months after onset
71
The only detectable serological marker in Hep B window period
anti-HBc (IgM)
72
The period covering the interval between disappearance of HBsAg and appearance of anti-HBsAg
window period
73
Major pathologic lesions in alcoholic liver disease
- fatty liver
- hepatitis
- cirrhosis
74
Management for end-stage cirrhosis in ALD
Liver transplantation
75
When do you give steroids (prednisone) or pentoxifylline in ALD?
Discriminant function (DF) >32 or MELD >20
76
Mainstay of treatment for hepatic encephalopathy
Lactulose
77
Preffered site for paracentesis
LLQ
78
Most common cause of ascites
Liver cirrhosis (84%)
79
Initial treatment of cirrhotic ascites
Na restriction
*Next line: spironolactone+furosemide
80
SAAG level to diagnose portal hypertension
SAAG >/= 1.1g/dl
81
Turbid ascitic fluid is ascribed to ____
infection or tumor cells as cause of ascites
82
White, milky fluid that indicates triglyceride level >200mg/dl is the hallmark of which type of ascites?
chylous ascites
83
Ascites that is dark brown fluid (reflecting high bilirubin) is due to ____
Biliary tract perforation
84
Black fluid in ascites is due to ____
pancreatic necrosis or metastatic carcinoma
85
Ascitic glucose <50 mg/dl, ascitic LDH > serum LDH, and multiple organisms on culture indicates what?
Secondary peritonitis from ruptured hollow viscus
86
Ascitic amylase usually >1000mg/dl is seen in which type of ascites?
Pancreatic ascites
87
Ascitis fluid lymphocytosis, AFB smear, TB culture, and elevated ascitic adenosine deaminase is seen in which condition?
Tuberculous peritonitis
88
Gold standard for evaluation when cause of ascites remains uncertain
Laparotomy or laparoscopy with peritoneal biopsy for histology and culture
89
"Apple-core" or "napkin-ring" deformity on xray is seen in which condition?
Colon cancer
90
Backbone of treatment of colon cancer
5-FU systemic therapy
91
Chemotherapeutic agent that prolongs survival in colon cancer when disease has progressed while on 5-FU therapy
Irinotecan (topoisomerase inhibitor)
92
Most common physical sign in hepatocellular cancer
Hepatomegaly
93
Tumor marker for HCC
AFP
94
Vascular abnormalities seen in liver ultrasound of HCC
- hypervascularity
| - thrombosis by tumor invasion
95
Used to determine tumor size, exten, presence of vascular (portal vein) invasion in HCC
Triphasic CT scan of abdomen and pelvis
96
Imaging criteria developed for HCC that do not require biopsy proof
- nodules >1cm with arterial enhancement and portal venous washout
- for small tumors, specified growth rates on 2 scans performed <6mos apart
97
Synovial fluid described as clear, viscous, amber-colored, WBC <2000/uL, with predominance of mononuclear cells is classified as ___?
Non-inflammatory synovial fluid
98
Synovial fluid that is turbid, yellow, WBC 2000-50,000/uL, PMN predominance, reduced viscosity is classified as ____?
Inflammatory synovial fluid
99
Synovial fluid that is opaque, purulent, WBC >50,000/uL, PMN predominance (>755%), low viscosity is classified as __?
Septic synovial fluid
100
Best initial diagnostic step for osteoarthritis
xray of affected joint
101
Best initial treatment for osteoarthritis
Paracetamol
102
Pathologic sine qua non of osteoarthritis
hyaline articular cartilage loss
103
Most important risk factor for developing osteoarthritis
Age
*OA is the most common cause of chronic knee pain in persons >45 yo
104
Which joints are affected in OA but not in RA
DIP
105
Typical xray finding in osteoarthritis
Joint space loss or narrowing
106
Joint pain is activity related and morning stiffness is <30 mins
OA
107
Lesions of the DIP seen in OA
Heberden's nodes
108
Lesions of the PIP seen in OA
Bouchard's noes
109
Symmetric polyarthritis with stiffness worst (>1hr) in the morning but eases with physical activity
RA
110
Initial diagnostic step for RA
Rheumatoid factor (RF) and anti-citrullinated peptide (anti-CCP) antibodies
111
Single most accurate test for RA
anti-CCP antibodies
112
Initial treatment of choice for RA
DMARDs (Methotrexate)
113
Pathologic hallmarks of RA (3)
1. synovial inflammation
2. focal bone erosions
3. thinning of articular cartilage
114
"swan neck deformity"
"Boutonnuere deformity"
"Z-line deformity"
Piano-key movement of ulnar styloid
RA
115
Most common hematologic abnormality in RA
normocytic normochromic anemia
116
Nodular RA + splenomegaly + neutropenia
Felty's syndrome
117
Most common pulmonary manifestation of RA
Pleuritis
118
Most common valvular abnormality in RA
Mitral regurgitation
119
Sensitivity of serum RF
75-80%
120
Specificity of anti-CCP antibodies for RA
95%
121
In the Classification Criteria for RA, what score indicates definite RA?
Score >/= 6
122
Initial readiographyc finding in RA
Periarticular osteopenia
*Others: soft tissue swelling, joint space loss, subchondral erosions
123
Synovial fluid analysis result in RA
```
Inflammatory fluid (WBC 5,000-50,000)
Overwhelming cell type: Neutrophils
```
124
Hydroxychloroquine (DMARD) serious side effect
irreversible retinal damage
125
DMARDs safe in pregnancy
Hydroxychloroquine,
| Sulfasalazine
126
Best initial diagnostic for Gouty arthritis
diagnostic arthrocentesis
127
Best initial therapy for gout
NSAID (those with short half-life):
| - Indomethacin, naproxen, ibuprofen, diclofenac, celecoxib
128
Classical presentation of gout
Podagra (pain in 1st metatarsophalangeal joint)
129
(+) negatively birefringent needle-shaped monosodium urate crystals
gout
130
(+) positively birefringent rhomboid-shaped calcium pyrophosphate dehydrate (CPPD) crystals
pseudogout
131
Most common type of arthritis
OA
132
Commonly affected joints in OA
- spine (cervical/ lumbosacral)
- hip
- knee
- 1st MTP
133
Simplest effective treatment for OA
Avoid activities that precipitate pain
134
Most common form of chronic inflammatory arthritis and often results in joint damage and disability
RA
135
Most frequently involved joints in RA
- wrists
- MCP
- PIP
- DIP (if with coexisting OA)
136
Frequent hallmark of RA and leads to decreased ROM, reduced grip, and trigger finger
Flexor tendon tenosynovitis
137
Defined as either keratoconjunctivitis sicca (dry eyes) or xerostomia (dry mouth) with another CTD, such as RA
Sjorgen Syndrome
138
Most frequent site of cardiac involvement in RA
Pericardium
139
Most common cause of death in those with RA
Cardiovascular disease
140
Most useful for confirming an inflammatory arthritis (vs OA), while at the same time excluding infection of gout
synovial fluid analysis
141
Offers greatest sensitivity for detecting synovitis and joint effusions, and early bone/bone marrow changes
MRI
142
Early sign of inflammatory joint disease and can predict subsequent development of erosions
Bone marrow edema
143
Population most affected by gout
Middle-aged to elderly men and postmenopausal women
144
Most common early clinical manifestation of gout
Acute arthritis; usually only 1 joint is affected (metatarsophalangeal joint of 1st toe is often involved)
145
Most commonly used hypouricemic agent and is the best drug to lower urate in overproducers, stone formers, and renal disease
Allopurinol
146
Joint most commonly affected in calcium pyrophosphate deposition disease (CPPD)
Knee
147
Drugs for uric acid undersecreter
- probenecid
- benzbromaronr
- sulfinpyrazone
148
Drugs for uric acid overproducer
- allopurinol
| - febuxostat
149
Best initial diagnostic test for SLE
ANA (antinuclear antibody)
*(+) in >98% of patiens with SLE
150
Most specific diagnostic test for SLE
Anti-dsDNA (70%) or Anti-Sm (25%)
151
What diagnostic test correlates with SLE disease activity?
Anti-dsDNA
152
SLE in pregnancy should be controlled with ___?
hydroxychloroquine +/- prednisone or prednisolone
153
Mainstay tx for non-life threatening SLE
analgesics and antimalarials
154
Mainstay tx for life-threatening SLE
systemic glucocorticoids PO/IV
155
Antihistone antibodies are frequently positive in which type of lupus
Drug-induced lupus
156
Most serious manifestation of SLE
Lupus nephritis
157
Leading cause of mortality in the 1st decade of SLE
nephritis and infection
158
Most common acute rash of SLE
Butterfly rash
159
Most SLE px have intermittent polyarthritis, most commonly in __
hands, wrists, knees
160
Most common chronic dermatitis in lupus (lesions: circular, slightly raised, scaly hyperpigmented erythematous rims and depigmented, atrophic centers)
Discoid LE
161
Most common manifestation of diffuse CNS lupus
cognitive dysfunction
162
Most common pulmonary manifestation in SLE
pleuritis +/- pleural effusion
163
Most common cardiac manifestation in SLE
pericarditis
164
Most serious cardiac manifestation in SLE
Myocarditis, Libman-Sacks endocarditis
165
Endocardial involvement in SLE can lead to valvular insufficiencies, most commonly of the ___
mitral or aortic valves
166
Most common hematologic manifestation in SLE
anemia (normo, normo)
167
Most common musculoskeletal manifestation in SLE
arthralgia/myalgia
168
Most common cutaneous manifestation in SLE
photosensitivity
169
Most important auto-antibody to detect in SLE
ANA
170
Medications approved for use in SLE
- NSAIDs
- salicylates
- hydroxychloroquine
- oral steroids
- IV methylprednisolone
171
SLE with worst prognosis
Crescentic lupus nephritis
