IMC/FM/EMED GI Flashcards
Define Esophageal Ring
What syndrome can this develop
Define Esophageal Web
Schatzki ring- mucosal stricture in distal esophagus at squamocolumnar junction
Steakhouse: progressive dysphagia w/ solids eaten fast
Thin membrane across lumen in mid/upper esophagus
? syndrome can develop w/ esophageal webs
Define Hiatal Hernia
Define Ventral Hernia
Plummer Vinson: Fe deficient anemia Dysphagia Glossitis Cheilosis Webs
Stomach protrudes through diaphragm via esophageal hiatus
Abdominal mass at previous incision site or d/t obesity
When do umbilical hernias need surgical referral
What are the two types of inguinal hernias
Persists >2yrs of life
Indirect- MC
Intestine passes through inguinal ring into canal, possibly into scrotum
Direct:
Intestine passes through external ring at Hesselbach triangle, rarely enters scrotum
Define Strangulated hernia
Define Obstructed Hernia
Define Incarcerated
Blood supply has been impaired
Irreducible hernia w/ intact blood supply
Occluded and irreducible, can progress to strangulated
? is the main RF for esophagitis
Endoscopy for esophagitis work up shows multiple, shallow ulcers d/t ?
What are the etiologies of non-infectious esophagitis
ImmComp
HSV
Corrosive Reflux Eosinophilic Medication Radiation
Two MC meds that cause medication induced esophagitis
When is Eosinophilic Esophagitis a considered Dx
What would be seen on barium swallow and how is it definitively dx
NSAIDs, Bisophosphonates
Asthma and GERD non-responsive to antacids
Ribbed esophagus w/ multiple corrugated rings; Biopsy
? radiation drugs can cause esophagitis?
Radiation exposure exceeding ? much puts these Pts at risk for ?
What are the hallmark signs of infectious esophagitis
Doxorubicin
Bleomycin
Cyclophosphamide
Cisplatin
5000 cGy;
Stricture
Odynophagia- pain while swallowing food/liquids
Since esophagitis primarily occurs in ImmComp Pts, what are the MC microbes
What would be seen on exam if etiology was fungal
What would be seen on PE if etiology was viral and how they’re Tx
C albicans
HSV
CMV
Linear yellow/white plaques w/ odynophagia
HSV- shallow punched out lesions; Acyclovir
CMV- large, solitary ulcer; Ganciclovir
? infectious causes of esophagitis may be seen in a non-ImmComp Pt
How is esophagitis Dx
How is esophagitis Tx depending on cause
EBV
Mycobacterium
Biopsy Culture Endoscopy
Double contract esophogram
Candida: Fluconazole
HSV: acyclovir
CMV: ganciclovir
Corrosive: steroid
Chronic GERD puts Pts at risk for ? Dz
What are Pts at risk for if the above issue develops
What is the gold standard and test of choice for Dx
Barretts; f/u screening q3-5yrs
Adenocarcinoma
Gold: pH probe; upper GI study is anatomic only
ToC: endoscopy w/ cytologic washings
Pts w/ GERD Sxs and ? RFs are considered high risk and need endoscopy
How is GERD Tx
Age >50 Hematemesis Weight loss Anemia/melena Recurrent vomiting Dysphagia
H2 antagonist, BID
Sxs persist- switch to PPI
Continue x 8wks after Sxs are controlled
Define Achalasia
What will be seen on swallow studies
What is the best study for Dx
Primary esophageal motility d/o w/ absent peristalsis
Bird beak/Rat tail
Manometry- shows absent peristalsis
How is achalasia Tx
What can be used for medical therapy
What will prevent the strictures from returning after surgery
EGD dilation of esophagus or mytomy
Nitroglycerine
CCBs
PPIs
Achalasia develops d/t loss of ? neuro structure
Define Diffuse Esophageal Spasm
What would be seen on a barium swallow
Auerbachs plexus
Non-peristaltic contractions causing pain after ingesting hot/cold substances
Corkscrew appearance
What is the best method to confirm a Dx of esophageal spasm after a barium swallow
How is this Tx
How does esophageal cancer present
Manometry; w/ Nitrates or CCBs
Dysphagia to solids progressing to liquids w/ adenopathy
What is the MC type of esophageal Ca
What part of the esophagus is MC affected
Hx of ? puts ? population more at risk for esophageal Ca
World: SCC
USA: Adeno d/t GERD/Barretts
Distal
Men who smoke
How is esophageal Ca Dx
How is this Tx
What two Sxs are common indicators of gastritis
Upper endoscopy w/ biopsy- test of choice
CT for staging
Resection, Radiation, Chemo w/ 5-FU
Dyspepsia, Abdominal pain
Acute Gastritis usually develops in ? part of stomach
What are the two types of Chronic Gastritis
Antrum
Type A- usually in fundus d/t anti-parietal Abs, associated w/ Pernicious Anemia; risk for AdenoCa
Type B- usually in antrum d/t NSAIDs, Pylori and often ASx; risk to develop PUD
How is Gastritis Dx
What are 3 methods to detect H Pylori
How is this Tx
Endoscopy w/ 4 biopsies
Fecal Ag
Serology
Urea breath test
Mild: Famotidine Cimetidine Frequent/Sev: PPI, taper and d/c when ASx x 8wks
What is the next step in gastritis Tx if Sxs return w/in 3months of d/c acid suppression
What RF increases incidence of gastric ulcers and slow healing time
What are the two types of ulcers and where are they MC seen
Upper endoscopy
Smoking
Duodenal- majority
Distal stomach
How do duodenal ulcers present on exam
95% of these ulcers are caused by ?
What side of the duodenum do these present on and why is location important
Pain decreased w/ food
H Pylori
Majority: anterior
Posterior have increased bleeding risk (gastroduodenal artery) or acute pancreatitis
PUD can rarely be caused by ? syndrome
How is this syndrome Dx
Gastric ulcers are MC found located ?
Zollinger Ellison- gastrinoma of pancreas causing excess gastrin to be released
Serum gastrin >200
Lesser curvature of antrum
? is the MCC of non-hemorrhagic GI bleed
This MC typically presents as ?
PUD
Melena
What is the most accurate Dx test for PUD
All Pts undergoing this test need ? additional test
What would be seen on labs/rads if an ulcer ruptured
Upper endoscopy
H pylori biopsy
Elevated serum amylase
Air under diaphragm
How is PUD Tx
When is Pylori eradication testing indicated
How are Pts w/ NSAID induced PUD Tx
All Pts- PPI
H Pylori:
PPI Amoxicillin Metro/Clarithro
4 or more weeks after completing therapy
PPI for minimum of 8wks
What is the mnemonic for gastric Ca
What are the MC early Sxs
What is the MC Sx
WEAPON: Weight loss Emesis Anorexia Pain Obstruction Nausea
Mild discomfort
Indigestion
Weight loss
What is the supraclavicular lymph node involved w/ gastric Ca
What is the opposite side node involvement
? is the MC type of gastric Ca in the world
Virchows, L side
R side: Hodgkins d/t etiology in mediastinum and drainage of mediastinum
Adenocarcinoma
What is the most important RF for gastric Ca
What are the two metastatic signs of gastric Ca
This can be Dx w/ endoscopy and biopsy w/ ? lab result
H pylori
Virchows- L supraclavian
Mary-Joseph nodule- umbilical
Linitis plastica- thickening of stomach wall d/t infiltration
How is gastric Ca Tx
What blood test is used to Dx Celiac Dz
How is the Dx confirmed after ? positive test
Gastrectomy
Rad and Chemo
IgA endomysial Ab
IgA transglutaminase Ab
+ endymysial Ab:
Intestinal mucosal biopsy from duodenal bulb
Celiac Dz may need correction of ? deficiencies
What causes lactose intolerance
Pts may need ? supplementation
Fe B12 Folate Ca Vit D
Dec lactase to convert lactose in glucose/galactose
Ca
How is lactose intolerance Dx
Fecal pH test can also be performed w/ ? being normal
What could make results be abnormal
Lactose breath H test
+= 20ppm over baseline
Normally alkaline
Acidic=
Lactose intolerance
E Coli
Rotavirus
Crohns can involve anywhere in the GI tract except leaving ? unaffected
What pattern would be seen on colonoscopy
What type of pain/diarrhea do Pts have
Rectum
Skip lesions/cobble stoning
Non-bloody w/ abdominal pain
UC involves ? part of the GI tract
What pattern would be seen on colonoscopy
What type of pain/diarrhea do Pts have
Only colon; MC rectum
Continuous erythematous/friable ulceration
Bloody diarrhea w/ rare abdominal pain
? Inflammatory Bowel Dz is associated w/ perianal dzs/fistulas
What radiographic finding is used to describe Crohns and UC
What histological features may be seen
Crohns
C: string sign in terminal ileum
U: lead pipe appearance w/ lost haustral folds
C: transmural, non-caseating granulomas
U: mucosa only crypt abscesses
? inflammatory bowel dz is slightly protected from by smoking
What serology results are used for Dx
Which one has bimodal distribution of prevalence
UC
Cr: ACSA
UC: p-ANCA
UC: 15-25, 55-65
What are two complications that can arise from UC
What lab result may be seen in UC not seen in Crohns
Why do UC Pts need LFTs
Toxic megacolon
Colorectal Ca
Anemia
Inc ALP and y-glutamyl transpeptidase suggest sclerosing cholangitis
When Tx IBDz w/ Sulfasalazine, supplement Pt w/ ?
Which IBDz can be cured by surgery
Folate
UC
How is UC/Crohns Tx
What is the next step if Pts don’t respond to initial Tx
What is used for acute exacerbation w/ no response to the above step
If Pt still doesn’t respond, what is the next step
Sulfasalazine w/ Folate
Mesalamine- UC>Crohns
Metronidazole
Pred/Budesonide
ImmSupp w/ steroids:
Azathioprine
6-Mercaptopurine
What medication needs to be added to IBDz Tx in Pts w/ terminal ileal dz
What meds need to be avoided
What criteria is used for Dx IBS
Cholstyramine
Colestipol
Antidiarrheals- induces ileus
Rome: Pain x 3d/mon in past 3 mon w/ 2/> of: Improved w/ BM Change in frequency Consistency change
What are 3 common Sxs in IBS
What red flags make the Rome Criteria for Dx invalid
Why are labs not ordered
Bloating
N/V
Rectal bleeding
Weight loss
Fever
Will be normal in IBS
How is IBS Tx
Infection of C Diff leads to ? type of colitis
How do Pts present
Hyoscyamine before meals for antispasmotic effect
Pseudomembranous
Fever w/ peritonitis and shock
How is Toxic Megacolon Dx
How is it Tx
? is the MC vessel blocked during intestinal ischemia
Diameter >6cm
Decompression
Resection
Superior Mesenteric artery
How do Pts w/ Ischemic Colitis present
What would be seen on x-rays
How is it Dx by gold standards and how is it Tx
PooP w/ Afib/MI/CHF
Thumb print sign
Angiography;
Revascularization
? two meds can help prevent formation of new polyps
Polyp growths are the MCC of ? in Peds
These tend to be more malignant w/ ? association
ASA, Cox-2 inhibitors
Painless rectal bleeding
More superior in intestine they are
Define Familial Adenomatous Polyposis
When do first degree relatives need screening
How often should screening be performed
Thousands of polyps by 15y/o, Ca by 40y/o
Genetic screening after 10y/o
Annual sigmoidoscopy starting at 12y/o
Once Polyps are identified on colonoscopy, how often are f/u needed
? is the MCC of lower GI bleeds and how does this MC present
What presentation signals this Dx is probably present
q3-5yrs
Diverticulosis
Painless rectal bleeding in elderly Pt w/ LLQ pain
Presence of what 3 PE finding suggest w/ Sp98% and Sn97% that diverticulitis is present
How is diverticulosis Dx
What image needs to be done in all Pts and what needs to be avoided
No vomiting
CRP >5mg/dL
LLQ tenderness
CT w/out contrast: fast stranding w/ wall thickening
X-ray r/o free air;
Avoid colonoscopy
How much fiber is recommended when Tx constipation
What are the bulk-forming laxative
What are the osmotic laxatives
What are the suppositories used for constipation Tx
20-25g/day
Psyllium seed
Methylcellulose
Ca polycarbophil
Dextrin
Polyethylene glycol
Glycerin
Bisacodyl
How does Hep A transmit and w/ ? travel link
How do Pts present
How long are they contagious
What education is given to Pt and what is given prophylactic to family
Fecal-Oral from Asia
Hepatomegaly
Jaundice
Until 1 week of jaundice
Life long immunity;
IV-IGg
How does Hep B present
? lab finding suggests some form of immunity is present
? lab finding suggests an infection is present
What lab result suggest acute Hep B process
What lab result suggests a resolved/chronic Hep B
Flu-like and Jaundice
Anti-HBs (HepBSAb)
HBsAg
Anti-HBc IgM
Anti-HBc IgG
How does Hep C present
What is the MC route of transmission
What is used for screening and Dx
? risk are these Pts at for later in life
Flu-like Sxs w/ RUQ pain
IVDA
Anti-HCV Abs;
HCV RNA quant
Hepatcellular cancer
What drugs are used for the Tx of Hep C
Hep D can only occur w/ ? and w/ ? differences
How is Hep D transmitted
Sofosbuvir
Grazoprevir
Daclatasvir
Hep B; more severe hepatitis and faster progression to cirrhosis
Clotting factors
Drug use
How is Hep E transmitted
When is this form dangerous
How is it Dx
Fecal-Oral waterborne outbreak
Infant mortality if pregnant
IgM anti-HEV
How is Hep D Tx
What is used for Hep E if RNA is detected in stool/serum for >6mon
Define Cirrhosis
PEG-IFN x 12mon
Ribavirin
Regenerative nodules surrounded by fibrotic tissue preventing regeneration
What are the two MC causes of cirrhosis
? autoimmune d/o can cause this
What classic skin changes can be seen on PE
Chronic Hep C
Alcohol abuse
Wilson’s Dz
Spider angiomata
Palmar erythema
Caput medusa
What lab is ordered at the time of a cirrhosis Dx
What screening do they need
Cirrhosis Pts presenting w/ fever and abdominal pain have ? Dx
A-fetoprotein followed by MRI
Abdominal US q6mon
EGD
Spontaneous bacterial peritonitis
Define Budd Chiari
What triad do Pts present w/
Usually ? lab ratio is seen in cirrhosis
Hepatic vein thrombosis
Abdominal pain
Ascites
Hepatomegaly
AST>ALT
? is the gold standard Dx test for cirrhosis
What mortality scoring system is used
How is hepatitis d/t autoimmune or Wilsons Tx
Liver biopsy
Child-Pugh, 1 and 2yr survival:
A: 5-6pts 100-85%
B: 7-9pts 81-57%
C: 10-15pts 45-35%
Auto: CCS
Wilson: Penicillamine
What is used for cirrhosis Pts prophylaxis against variceal hemorrhage
How is cirrhosis related encephalopathy Tx
How is cirrhosis related ascites Tx
How is cirrhosis related pruritus Tx
Non-Selectives:
Nadolol + Propranolol
Lactulose + Neomycin
Na restriction, centesis
Cholestyramine
? tumor marker is used for liver Ca
Hepatocellular Ca often occurs in setting of ? two Dxs
How does Dx depend on the size of lesion
Alpha-fetoprotein
Chronic liver dz
Cirrhosis
<1cm: MRI
Neg= US q3mon
Define Cholecystitis
What PE finding aids w/ Dx
Chronic cholecystitis can lead to ? condition
Inflammation of gallbladder from gallstones/obstruction
Murphys- RUQ pain w/ inspiration
Boas- R subscapular pain d/t phrenic nerve irritation
Porcelain gallbladder, premalignant
How is cholcystitis Dx
Define Cholangitis
What triad can this present with and ? makes it a pentad
First: US
Gold: HIDA
Infected obstruction d/t E Coli
Charcots: Fever RUQ pain Jaundice \+HOTN and Confusion
What bowel/bladder changes are reported during cholangitis
Define Sclerosing Cholangitis
This commonly occurs in Pts w/ ? Dx and presents as ?
Light stool, dark urine d/t common duct obstruction
Cholestasis w/ inflammation/fibrosis or bile ducts
UC;
Pruritus and Jaundice
How is cholangitis Dx
How is it Tx
Define Cholelithiasis
RUQ US but,
ERCP is optimal
+Charcot and abnormal liver test: direct to ERCP
ERCP for stone removal
Gallstones w/out inflammation
? is the cardinal Sx of cholelithiasis
How is this Dx
What lab result is elevated when there is obstructed bile flow
Biliary colic
RUQ US after 8hrs of fasting
ALK-P
What mnemonic is used for DDxs for pancreatitis
GET SMASHED Gallstone Ethanol Trauma Steroids Mumps Autoimmune Scorpion sting HyperCa Hyperlipids ERCP Drugs
? criteria is used to predict severity of acute pancreatitis
What are poor predictors for criteria at admission
How is chronic pancreatitis’ presentation different
Ranson
Age >55y/o Leukocyte >16K Glucose >200 LDH >350 AST >250
Steatorrhea,
Malabsorption
What is the classic triad for chronic pancreatitis
? lab result is more specific for pancreatitis
What is the Dx test of choice
Pancreatic calcification
Steatorrhea
DM
Serum lipase 3x higher
CT
Xray: sentinel loops
What part of PE may clue to pancreatitis on written exams
? is the best/most important part of pancreatitis Tx
What tumor marker is used for pancreatic Ca
Dec bowel sounds
IV fluids
CA 19-9
Define Courvoisiers Sign
What is the MC type of pancreatic neoplasm
What is this type of Ca associated w/
Nontender, palpable gallbladder suggesting pancreatic neoplasm
Ductal adenocarcinoma at pancreatic head
Cigarette Pancreatitis Obesity DM
What PE finding suggests pancreatic cancer has spread and is inoperable
How is pancreatic Ca Dx
How is this Tx
Pain relieved w/ sitting forward
Ct and Inc amylase
Whipple Procedure: Gallbladder Stomach antrum Pancreatic head Duodenal section
What are the 3 types of hemorrhoids
How does each type present
External: distal to dentate
Internal: prox to dentate
Mixed: both
Internal: painless, bloody w/ sensation of incomplete void
External: pain, no bleeding
How are hemorrhoids graded
Pts w/ anal fistulas need ? Dz considered
Fistulas are usually located w/ in ? far from anal margin
1: visible, no prolapse
2: prolapse, spot reduce
3: prolapse, manual reduction
4: irreducible, can strangulate
Crohns
3cm
How are anal abscesses Dx
How are perianal fistulas Dx
Define Kwoshiorkor
Clinical
Recurrent= CT
Anoscopy
Deficient protein
Define Marasumus
What happens during deficient fat soluble vitamins
Deficiency of all energy forms
A: night blindness
D: rickets
E: neuropathy
K: bleeding
What happens in Thiamine deficiency
What happens in Niacin deficiency
What happen in Pantothenic Acid deficiency
B1- Beriberi, Wernickes, Korsakoff syndrome
B3- Pellagra
B5- numb/tingles
What happens in Pyridoxine deficiency
What happens in folate deficiency
What happens in cobalamin deficiency
B6- atrophic glossitis, siderblast anemia
Neural tube defect, megablast anemia
B12- megablast anemia, cord degeneration
