IM- GI Flashcards
The 3 risk factors for C-Diff colitis
- Recent abx
- Hospitalization
- PPI
The 3 clinical presentations for C-Diff colitis
- Profuse diarrhea
- Fulminant colitis or
- Toxic megacolon
How do you diagnosis C-diff?
Stool PCR
How do you treat C-diff?
Oral vancomycin or fidaxomicin
the presence of “succussion splash” heard on auscultation of the upper abdomen indicates?
Gastric outlet obstruction (GOO)
Dysphagia and halitosis
Zenker diverticulum
- also regurgitation and aspiration
How to diagnosis Zenker Diverticulum?
Barium esophagram
Esophageal manometry
How do you manage Zenker diverticulum?
With open/endoscopic Surgery
or
cricopharyngeal myotomy
The 3 risk factors for pancreatic cancer that are hereditary include
- 1st degree relative with pancreatic cancer
- Hereditary pancreatitis
- Germline mutations (BRCA 1, BRCA 2, Peutz-Jeghers syndrome)
The 3 risk factors for pancreatic cancer that are enviromental include
- Cigarette smoking (most significant)
- Obesity, low physical activity
- Nonhereditary chronic pancreatitis
If U/S suggests intrahepatic cholestatsis, and you suspect PBC (primary biliary cholangitis), what is the next step
obtain serum anti-mitochondrial antibody titers, which are highly sensitive to PBC
What are the 3 main causes of steatorrhea and with others that are rare
- Pancreatic insufficiency
- Bile salt-related
- Impaired intestinal surface epithelium
- others that are rare
Causes of steatorrhea from pancreatic insufficiency (2)
- Chronic pancreatitis (alcohol abuse, cystic fibrosis, or autoimmune/hereditary pancreatitis)
- Pancreatic cancer
Causes of steatorrhea from bile salt-related problems (5)
- Small-bowel Crohn disease
- Bacterial overgrowth
- Primary biliary cirrhosis
- Primary sclerosis cholangitis
- Surgical resection of ileum
Causes of steatorrhea from impaired intestinal surface epithelium (3)
- Celiac disease
- AIDS enteropathy
- Giardiasis
Causes of steatorrhea from rare conditions (3)
- Whipple disease
- Zollinger-Ellison syndrome
- Medication-induced
Hyperestrinism in cirrhosis leads to 5 conditions
- Gynecomastia
- Testicular atrophy
- decreased body hair
- spider angiomas
- palmar erythema
What is Rome diagnostic criteria?
Used to diagnose irritable bowel syndrome (IBS)
What criteria are included in Rome to diagnose IBS
Recurrent abdominal pain/discomfort > or = 3 days/month for the past 3 months & > or = 2 of the following
- Symptom improvement with bowel movement
- Change in frequency of stool
- Change in form of stool
The steps in managing bleeding esophageal varies
- Hemodynamic support (IVF bolus…)
- Pharmacologic treatment (octreotide)
- endoscopic therapy (band ligation, sclerotherapy)
- Prophylactic abx
Upper Endoscopy shows multiple stomach ulcer and thickened gastric folds, suspected Dx?
Gastrinoma (Zollinger-Ellison syndrome)
What is your next step after endoscopy for Gastrinoma suspicion?
Check serum gastric level after off PPI therapy for 1 week
If gastric level is >1000pg/ml what is your next step?
Check gastric pH off PPI therapy for 1 week
if pH is < or = 4 for suspected gastrinoma what is your next step?
Further testing to localize gastrinoma
if pH <4 it is not gastrinoma
Serum gastrin level off PPI therapy for 1 week shows 110-1000 pg/ml what is the next step?
Secretin stimulation test; if + it is Gastrinoma and do further testing to localize
if - it is not gastrinoma
What are the 3 risk factors for Acalculous cholecystitis?
- Severe trauma or recent surgery
- Prolonged fasting or TPN
- Critical illness (sepsis, ICU)
Clinical presentation for Acalculous cholecystitis?
- Fever, leukocytosis, Elevated LFT’s, RUQ pain,
- Jaundice and RUQ mass (less common)
What is the treatment for C-diff with initial episode?
- Vanomycin PO
or - Fidaxomicin
What is the tx for C-diff 1st recurrence?
Vancomycin PO in a prolonged pulse/taper course
or
Fidaxomicin if vancomycin was used in initial episode
What is the tx for C-diff multiple recurrence?
- Vancomycin PO followed by rifaximin
- Fecal microbiota transplant
What is the tx for Fulminant C-diff like hypotension/shock, ileum, megacolon?
- Metronidozole IV
+ high-dose vancomycin PO (or per-rectum if ileum is present) - Surgical evaluation
Acute liver failure is defined as severe acute liver injury without underlying liver disease and it’s 3 characteristics include
- elevated aminotransferases (often >1000)
- Hepatic encephalopathy
- synthetic liver dysfunction (defined as prolonged PT with INR >1.5)
Treatment for Acute liver failure
Transplant
Only half of pt with out transplant will survive
Ascites fluid with bloody color cause (3)
- Trauma
- Malignancy
- TB (Rare)
Ascites fluid with milky color cause (2)
- Chylous (lymph and emulsified fats/FFA)
- Pancreatic
Ascites fluid with turbid color cause
Possible infection
Turbid- cloudy, opaque or thick with suspended matter
Ascites fluid with straw color cause
benign causes
Ascites fluid with neutrophils count >250 means
Peritonitis (secondary or spontaneous bacterial)
Ascites fluid with total protein <2.5 (low protein ascites), causes (2)
- Cirrhosis
- Nephrotic syndrome
Ascites fluid with total protein > or = 2.5 (high protein ascites)
- CHF
- Constrictive pericarditis
- pertoneal carcinomatosis
- TB
- Budd-Chiari syndrome
- Fungal (coccidioidomycosis)
Serum-ascites albumin gradient (SAAG) > or = 1.1 indicates
Portal Hypertension (cardiac ascites, cirrhosis, Budd-Chiari syndrome)
Serum-ascites albumin gradient (SAAG) < 1.1 indicates
Absence of portal hypertension
TB, Peritonea carcinomatosis, pancreatic ascites, nephrotic syndrome
Uncoordinated, simultaneous contractions of esophageal body
Diffuse esophageal spasm (DES)
Intermittent chest pain, dysphasia for solids and liquids
Diffuse esophageal spasm (DES)
How do you diagnose Diffuse esophageal spasm
- Manometry
- Esophagram
In Diffuse esophageal spasm, what do you see with Manometry
- Intermittent peristalsis
- multiple simultaneous contractions
In Diffuse esophageal spasm, what do you see with Esophagram
“Corkscrew” pattern
Jaundice triggered by fasting or consuming of a fat-free diet, physical exertion, febrile illness, stress or menstruation
Gilbert Syndrome
The 4 most common causes of cirrhosis in USA are
- Viral hepatitis
- Chronic alcohol abuse
- Nonalcoholic fatty liver disease
- Hemochromatosis
What are the treatments for diffuse esophageal spasm?
- CCB or Nitrates or Tricyclics
What can happen after several retching and vomiting?
Esophagus suptur (Boerhaave syndrome)
Treatment for nonalcoholic fatty liver disease
- Diet and exercises
- Consider bariatric surgery if BMI > or = 35
Temp >100F, Abd pain/tenderness, AMS, hypotension, hypothermia, paralytic ileum with sever infection is a clinical presentation for
Spontaneous bacterial peritonitis
Pt infected with H-Pylori can be predisposed to peptic ulcer disease- can present with those symptoms (3)
- Dyspepsia
- Postparandial fullness
- Nausea
The most common causes of liver metastases are (3)
- GI tract
- Lung
- Breast
Zollinger-Ellison syndrome 80% is Sporadic and 20% ?
MEN1
Markedly elevated serum gastrin (>1000pg/ml) in the presence of normal gastric acid (pH<4)
Zollinger-Ellison syndrome
Work up for Zollinger-Ellison syndrome
- Endoscopy
- CT/MRI & somatostatin receptor scintigraphy for tumor localization
Patients with Zollinger-Ellison syndrome have impaired fat absorption because of
Pancreatic enzyme inactivation
AST 3,720, ALT 3,250 with patient who was hypotensive what is the cause of abnormal liver function panel
Ischemic hepatic injury
In what area of the esophagus does Mallory-Weiss tears occur?
Distal esophagus at the GE junction (Gastroesophageal)
- With multiple episodes of nausea and vomiting
The most common cause of exudative pleural effusions that are infectious (4)
- Parapneumoniac
- TB
- Fungal
- Empyema
The most common cause of exudative pleural effusions that are non-infectious 2
Malignancy & PE
Three processes that cause transudate effusions
- Decreased intrapleural
- decreased plasma oncotic pressure
- Elevated hydrostatic pressure
Three processes that cause exudative effusions
- increased capillary permeability
- increased pleural membrane permeability
- Disruptions of lymphatic outflow
A complicated parapneumonic effusions will have pH?Glucose? WBC?
Tx should include _____ & ______
- pH <7.1
- Glucose <60
- WBC >50,000
- Tx with antibiotics and drainage
The tx for uncomplicated parapneumonic includes
Antibiotics (no need to drain)
Pt hospitalized for CAP (community acquired PNA) what kind of abx regimen (2)?
- Fluroquinolone (Moxifloxacine) or
- A beta-lactam plus macrolide (Ceftriaxone + azithromycin)
The common manifestation of systemic sclerosis? and its presentation
Pulmonary artery hypertension
- Dyspnea that leads to R ventricular enlargement and R sided heart failure
The common mechanism of pulmonary hypertension in Systemic sclerosis is ____________ leading to increased pulmonary vascular resistance
hyperplasia of the intimal smooth muscle layer of the pulmonary arteries
The 3 main problems that are ARDS patient lung has are
- Impaired gas exchange
- decreased lung compliance
- Pulmonary Arterial pressure
What is the impaired gas exchange in ARDS pt due to?
Ventilation-Perfusion mismatch
What is the decreased lung compliance in ARDS pt due to (2)?
- loss of surfactant &
- Increased elastic recoil of edematous lungs
What is the pulmonary arterial pressure in ARDS pt due to (3)?
- Hypoxic vasoconstriction
- Destruction of lung parenchyma
- compression of vascular structure from PEEP in mechanically vented pt
ACE inhibitors cause chronic nonproductive cough in 5-20% of pt due to? 4
- Increased Kinins
- Increased Substance P
- Increased Prostaglandins (causes bronchial irritation)
- Increased thromboxane (causes bronchoconstriction)
Clinical associations for Adenocarcinoma lung (2)
- Clubbing
- Hypertrophic osteoarthropathy (digital clubbing along with painful joint enlargement, periostosis of long bones, and synovial effusions)
Clinical associations for SSC of lung (1)
Hypercalcemia
Clinical association for SCC of lung (small cell carcinoma) (3)
- Cushing syndrome
- SIADH
- Lamber-Eaton syndrome
Clinical association for Large cell carcinoma of lung (2)
- Gynecomastia
- Galactorrhea
The 3 most common causes of secondary digital clubbing are
- Lung malignancies
- Cystic fibrosis
- R to L cardiac shunts
Pt with obesity hypoventilation syndrome and obstructive sleep apnea can develop (5)
- Chronic hypoxia
- Hypercapnia (with compensatory metabolic alkalosis)
- Secondary erythrocytosis
- Pulmonary hypertension
- Cor pulmonale
The kidneys way for metabolic alkalosis compensation for hypercapnia is by (2)
- Increased bicarbonate retention and
- Decreased reabsorption of Chloride
Waking up at night
feeling tired
chocking sensation
Obstructive sleep apnea
Acute episodes presents with cough, breathlessness, fever, and malaise,
Chronic exposure causes weight loss, clubbing, and honeycombing of the lung
antigen exposure - Hypersensitivity pneumonitis
Exudate is inflammation with plural fluid pH of
7.3-7.45
If pH <7.3 in pleural fluid it is mostly due to (2)
- Bacteria (empyema)
- or decreased hydrogen ion efflux from the pleural space (pleuritis, tumor, pleural fibrosis)
Dry cough, malaise for 2 months and bilateral hilar adenopathy
Sarcoidosis
Chronic multisystem disorder due to noncaseating granulomatous inflammation
Sarcoidosis
Erthyema nodosum
Hilar adenopathy
Migratory polyarthralgia
fever
Lofgren syndrome (Type of acute sarcoidosis)
Facial nerve palsy
central diabetes insipidus
hypercalcemia
Central nervous system/endocrine manifestation of sarcodosis
What will happened with pulmonary flow-volume loop in patient with fixed upper-airway obstruction (eg. laryngeal edema)
decreases the airflow rate during inspiration and expiration
Scooped-out pattern during exhalation in pulmonary flow-volume loop indicates
asthma- due to decreased airflow during the effort-independent phase of exhalation
- Cough with daily mucopurulent sputum production
- Rhinosinusities, dyspnea, hemoptysis
- Crackles, wheezing
Bronchiectasis
What are the testing used to evaluate bronchiectasis (5)
- High resolution (HRCT) scan of the chest (initial diagnosis)
- Immunoglobulin quantification
- CF testing
- Sputum culture (bacteria, fungi and mycobacteria)
- Pulmonary function testing
Upper lung lobe infiltrate is characteristic of bronchiectasis due to CF and the common bacteria is
Pseudomonas aeruginosa
Childhood history of recurrent infection (meningitis, PNA) that predisposes to bronchiectasis
Complement deficiency causes susceptibility to encapsulated bacteria
Hx of opportunistic infections (eg Candida, PCP) that predisposes to bronchiectasis
Cell-mediated immunity (DiGeorge syndrome, HIV)
Splenic dysfunction causing bronchiectasis
susceptibility to encapsulated bacteria, Sickle-Cell anemia
How is solitary pulmonary nodules defined? (4)
- Rounded opacity
- < or = 3cm in diameter (greater is mass)
- Surrounded by pulmonary parenchyma
- No associated lymph node enlargement
7 factors that increases malignancy of a solitary pulmonary nodules
- Large size
- Advanced age
- Female sex
- Active or previous smoking
- Family or personal hx of lung cancer
- Upper lobe location
- Spiculated radiographic appearance
What is the size of a solitary pulmonary nodule that require additional management or surveillance?
> 0.8cm
The 5 causes of middle mediastinal masses on chest x-ray include
- Tracheal tumors
- Pericardial cysts
- Lymphoma
- Lymph node enlargement
- aortic aneurysms of the arch
anterior mediastinum mass on chest x-ray is more likely to be
Thymoma
the 6 causes of Posterior mediastinum mass on chest x-ray are
- Meningocele (neurogenic tumors)
- enteric cysts
- Lymphomas
- Diaphragmatic hernias
- esophageal tumors
- Aortic aneurysms
