Kaplan IM - Gastroenterology Flashcards
1
Q
What is the presentation of GERD?
A
- Substernal chest pain without cardiac disease
- Chronic cough
- Belching
- Metallic or sour taste
- Wheezing without reactive airway disease
2
Q
Mention some major risk factors for GERD.
A
- Obesity –> BMI>28.
- Hiatal hernia
- Hypercalcemia –> Ca is 2nd messenger for gastrin.
- Zollinger-Ellison
- Medications –> Prednisone
- Motility disorders –> Scleroderma, gastroparesis (DM neuropathy)
- Cigarette smoking
- Xerostomia
3
Q
What is the best initial test for GERD?
A
PPI administration –> also therapeutic.
4
Q
What happens if after 4-6 weeks treatment failure of GERD with PPIs occurs?
A
The most accurate test is a 24h pH monitoring.
5
Q
What indicates endoscopy in GERD?
A
When symptoms persist after maximal therapy + In alarm symptoms:
- Dysphagia
- Odynophagia
- GI bleeding or anemia
- Weight loss
6
Q
When is 24h pH monitoring indicated?
A
- Asthma begins as an adult in the setting of GERD.
- Hoarseness persists for a prolonged duration.
- Sleep apnea is a comorbid finding
- Medical treatment has failed.
7
Q
What are the 3 steps in the treatment of GERD?
A
- Lifestyle modifications
- Medical therapy
- Surgical treatment
8
Q
What lifestyle modifications can be done to treat GERD?
A
- Elevate the head of the bed
- Stop tobacco, caffeine, chocolate, alcohol, and peppermint
- -> ALL reduce lower esophageal sphincter pressure. - Don’t sleep within 3 hours of a meal, when acid production in the stomach is at a peak.
- Lose weight.
9
Q
What is the medical therapy for GERD?
A
PPIs and H2 blockers.
10
Q
What percentage of patients is treated with H2 blockers?
A
Only 50-70%.
11
Q
What do the antacids provide?
A
Short-term relief in only 20% of cases.
12
Q
What is the surgical treatment of GERD?
A
- Nissen fundoplication
2. Transoral incisionless fundoplication (TIF) endoscopically rebuilds the LES through the esophagus.
13
Q
What is the difference between dysphagia and odynophagia?
A
Dysphagia –> Difficulty shallowing.
Odynophagia –> Painful shallowing.
14
Q
What is the probably the underlying cause of dysphagia in young patients and in old ones?
A
Young –> Secondary to a motility disorder.
Old –> Stroke is a more common cause.
15
Q
What is probably the underlying cause in odynophagia?
A
Typically in the setting of an infectious process and requires biopsy during EGD.
16
Q
Mention some causes of dysphagia.
A
- Achalasia
- Cancer
- Peptic strictures - rings from acid exposure.
- Zenker diverticulum - halitosis.
- Esophageal spasm
17
Q
What is the type of dysphagia in achalasia?
A
Solids and liquids.
18
Q
What is the etiology of achalasia?
A
Idiopathic and Chagas.
19
Q
What is the best initial test in achalasia?
A
Barium shallow with a “Bird’s beak” sign + massively dilated esophagus.
20
Q
What is the most accurate test in dysphagia caused by achalasia?
A
Esophageal manometry shows high LES pressure with shallowing and peristalsis.
21
Q
What is the best therapy for dysphagia caused by achalasia?
A
- Pneumatic dilation
- LES injections of botulinum toxin type A
- Heller myotomy
22
Q
What type of dysphagia do we see with esophageal cancer?
A
Progressive worsening from solids to liquids.
23
Q
What is the etiology of esophageal cancer?
A
- Long-standing GERD
- Alcohol
- Tobacco
24
Q
What is the best initial test for dysphagia caused by esophageal cancer?
A
EGD with biopsy and further imaging (CT scan, PET, ultrasound) for staging.
25
What is the most accurate test for dysphagia caused by esophageal cancer?
EGD - in cancer tissue biopsy only if definitive.
26
What is the best therapy for dysphagia caused by esophageal cancer?
Surgical resection and 5-fluorouracil therapy +/- radiation.
27
What type of dysphagia do we see with peptic strictures (rings from acid exposure)?
Solids or liquids.
28
What is the etiology of peptic strictures?
Long standing GERD.
29
What is the best initial test for dysphagia associated with peptic strictures?
Barium study.
30
What is the most accurate test for dysphagia associated with peptic strictures?
EGD is diagnostic and therapeutic.
31
What is the best therapy for dysphagia associated with peptic strictures?
Pneumatic dilation.
32
What type of dysphagia is associated with Zenker diverticulum (associated with halitosis)?
Solids and liquids.
33
What is the etiology of Zenker diverticulum?
Congenital.
34
What is the best initial test for Zenker diverticulum?
Barium study.
35
What is the most accurate test for dysphagia associated with Zenker diverticulum?
Barium study.
36
What is the best therapy for dysphagia associated with Zenker diverticulum?
Surgical resection or endoscopic stapling.
37
What type of dysphagia is associated with esophageal spasm?
Acute difficulty in shallowing solids and liquids with chest pain.
38
What is the etiology of esophageal spasms?
Diffuse, uncoordinated esophageal contractions.
39
What is the best initial test for dysphagia associated with esophageal spasms?
Barium study at time of attack showing a "corkscrew" esophagus.
40
What is the most accurate test for dysphagia associated with esophageal spasms?
Manometry in the setting of clinical symptoms.
41
What is the best therapy for esophageal spasms?
Ca channel blockers.
42
Mention some causes of esophagitis.
1. Candidiasis
2. CMV
3. HSV
4. Pill esophagitis
5. Eosinophilic esophagitis
43
What are the signs and symptoms of esophagitis due to candida?
Dysphagia + Odynophagia.
44
What is the diagnostic test for esophagitis due to candida?
Treat patients with AIDS who have <100 CD4 cells with fluconazole.
45
What are the signs and symptoms of esophagitis due to CMV?
Dysphagia and odynophagia in an immunocompromised patient.
46
What is the diagnostic test for CMV esophagitis?
EGD with biopsy with viral cultures.
47
What is the best therapy for CMV esophagitis?
Ganciclovir or foscarnet.
48
What are the signs and symptoms of HSV esophagitis?
Dysphagia and odynophagia in an immunocompromised patient.
49
What is the diagnostic test for HSV esophagitis?
EGD with biopsy with viral cultures.
50
What is the best therapy for HSV esophagitis?
Acyclovir.
51
What are the signs and symptoms of pill esophagitis?
New-onset dysphagia and odynophagia in a patient on biphosphonates or doxycycline.
52
What is the diagnostic test in pill esophagitis?
EGD to rule out other causes.
53
What is the therapy in pill esophagitis?
Prevention with copious water with pills and sitting up 3 hours postingestion.
54
What are the signs and symptoms of eosinophilic esophagitis?
Dysphagia and odynophagia in a young patient with atopy and normal motility.
55
What is the diagnostic test for eosinophilic esophagitis?
EGD with biopsy followed by allergen testing to identify causative agent.
56
What is the therapy for eosinophilic esophagitis?
Pneumatic dilatation + oral corticosteroid therapy.
57
What are the 4 levels of findings in which the biopsies for Barrett esophagus are categorized?
1. Non-dysplastic or Barrett esophagus --> Give PPIs and repeat EGD in 3 years.
2. Low-grade dysplasia --> Give PPIs and repeat EGD in 3-6 months.
3. High-grade dysplasia --> Surgical resection.
4. Carcinoma --> Surgical resection.
58
How is esophageal perforation caused?
By a sudden increase in intraluminal esophageal pressure with negative intrathoracic pressure caused by vomiting that leads to a full thickness tear.
59
With what can esophageal perforation present?
1. Severe retrosternal chest pain --> begins shortly after vomiting.
2. Odynophagia + hematemesis.
3. Crunching, rasping around, synchronous with the heartbeat from subcutaneous emphysema.
4. Radiation of the pain to the left shoulder.
60
What is the most accurate test for esophageal perforation?
Gastrografin esophogram --> will reveal extravasation of contrast outside the esophageal lumen.
61
What is the management of esophageal perforation?
1. Closure of the perforation is done surgically with debridement of the mediastinum.
2. Endoscopic stents can be placed to close the perforation in patients non amenable to surgery.
62
What is the presentation of Mallory-Weiss syndrome?
MUCOSAL tear due to vomiting that occurs commonly at the GE junction.
Presents with:
1. Chest pain
2. Hematemesis
3. Will not have subcutaneous air
Commonly occurs in alcoholics and bulimics.
63
Abdominal pain that is worse after eating indicates what?
Gastric ulcer.
64
Abdominal pain that is better with eating indicates what?
Duodenal ulcers.
65
Mention the major risk factors for peptic ulcer disease?
1. H.pylori infection
2. NSAIDs
3. Burns - Curling ulcers
4. Head injury - Cushing ulcers
5. IBD - Crohn
6. Cancer - tumor itself becomes ulcerated
7. Mechanical ventilation - stress gastritis
66
What is the prevalence of having an ulcer with NSAID use?
20%.
67
Are alcohol and smoking risk factors for peptic ulcer disease?
No - But they prevent ulcer HEALING.
| Do NOT directly cause ulcers.
68
What is the clinical presentation of peptic ulcer disease?
Patient presents with gnawing abdominal pain localized to epigastrium.
Severe ulcers may also have gastric outlet obstruction causing early satiety + bleeding leading to anemia and heme-positive stools.
MCC of epigastric pain is non-ulcer dyspepsia.
69
Is there a way to be certain of the etiology of epigastric pain without endoscopy?
No way.
70
What must be done in all vented patients?
Must be of PPIs to prevent stress ulcers.
71
How high is the risk of a gastric ulcer to proceed to cancer?
4%.
72
What is the mainstay of diagnosis in patients with suspected PUD?
Upper endoscopy.
73
Why are biopsies necessary with gastric ulcer?
To exclude cancer.
74
How do we make the diagnosis of H.pylori?
If endoscopy and biopsy are performed, NO FURTHER TESTING.
If endoscopy is not performed:
1. Serology
2. Breath testing and stool antigen
75
What diagnostic methods for H.pylori are highly specific ONLY for active infection?
Breath testing and stool antigen.
Neither of them is routine.
Useful as a test of cure after treatment, unless there is recurrence of symptoms.
76
What may affect the sensitivity of breath testing and stool antigen for H.pylori?
1. PPIs
2. Bismuth
3. Antibiotics
77
What is the treatment of peptic ulcer disease?
1. Discontinue NSAIDs
2. Treat H.pylori with triple therapy - PPI, clarithromycin, and amoxicillin.
3. Recurrent/persistent symptoms are likely due to either noncompliance or resistance.
4. Repeat endoscopy may be warranted if symptoms do not resolve.
5. Gastric ulcer must be re-scoped to ensure resolution of the ulcer.
78
What is the ONLY 100% accurate way to exclude cancer even if the biopsy is normal?
Gastric ulcer must be re-scoped to ensure resolution of the ulcer.
79
What is the presentation of Zollinger-Ellison syndrome?
1. Severe abdominal pain
2. Anemia
3. Watery diarrhea
4. Weight loss --> acid inactivates lipase
5. Anorexia
80
When should we suspect Zollinger-Ellison syndrome in those with PUD?
1. Multiple large ulcerations >1cm in size.
2. Ulcerations beyond the ligament of Treitz.
3. Symptoms after recurrent HP treatment.
81
Will secretin have any effect in Zollinger-Ellison?
No effect.
82
What are the most accurate tests for Zollinger-Ellison syndrome?
1. Endoscopic ultrasound (EUS)
| 2. Nuclear somatostatin scan
83
What advantage does EUS have?
Has the advantage of being able to directly gain tissue samples and endoscopically tattoo the lesion with ink for future surgical resection.
84
What is the treatment for Zollinger-Ellison?
Localized --> Surgical resection.
| Metastatic disease --> Lifelong PPI + chemotherapy + Tumor embolization (if hepatic) + octreotide.
85
How long does H.pylori treatment must go?
10-14 days.
86
What percentage of patients have H.pylori in their GI tracts?
More than 50%.
87
With what cancers is H.pylori associated?
1-2% lifetime risk of stomach canceer + less than 1% risk of gastric MALT lymphoma.
88
What percentage of MALT lymphomas of the stomach are associated with H.pylori?
80%.
89
What are the 4 major methods of testing for H.pylori?
1. Stool antigen testing --> used to evaluate for disease eradication.
2. Urease breath testing --> used to evaluate for disease eradication.
3. Serology is HIGHLY SENSITIVE --> cannot distinguish between previous infection and active infection.
4. EGD with biopsy and Giemsa staining is the most accurate test.
90
What is the most accurate test for diagnosing H.pylori?
EGD with biopsy and Giemsa staining.
91
What is the treatment for H.pylori?
PPI + Clarithromycin + Amoxicillin for 14 days.
| If allergic to penicillin --> Replace amoxicillin with metronidazole.
92
Every patient who starts infliximab must have what?
A PPD to detect latent TB.
93
Mild diarrhea is self-limiting. What defines severe diarrhea?
1. Fever
2. Abdominal pain
3. Hypotension
4. Tachycardia
5. Blood in the stool (most important diagnostic criteria)
94
What is the best initial test for diarrhea?
Fecal leukocytes.
95
What is the most accurate test for diarrhea?
Stool culture.
96
What is the treatment of diarrhea?
Fluid resuscitation antibiotics (fluoroquinolones) are useful for acute traveler's diarrhea and for severe disease.
97
Mention some causes of bloody diarrhea.
1. C.jejuni
2. E.coli
3. Salmonella
4. Shigella
5. Yersinia
6. Vibrio parahemolyticus
7. Giardia
8. Entamoeba histolytica
98
What is the cause of C.jejuni infection?
1. Fecal-Oral transmission
| 2. Raw meat
99
What are the features of C.jejuni diarrhea?
1. MCC of gastroenteritis
2. Febrile illness
3. Associated with Guillain-Barre + reactive arthritis
4. Left lower quadrant mimicking diverticulitis
5. Usually self-limited after 1 week
100
What is the treatment of C.jejuni diarrhea?
Macrolides - RESISTANT to fluoroquinolones.
101
What is the cause of E.coli diarrhea?
1. Undercooked beef
2. Fresh product
3. Unpasteurized dairy product
4. Petting zoos
102
What are the 3 main forms of E.coli diarrhea?
1. O157:H7 --> associated with HUS --> NEVER GIVE ANTIBIOTICS.
2. ETEC --> Traveler's diarrhea.
3. Enterohemorrhagic.
103
What is the cause of Salmonella diarrhea?
Chicken and eggs.
104
What is important to keep in mind about salmonella diarrhea?
Usually self-limited.
105
What is the cause of shigella diarrhea?
Shiga toxin: most severe.
106
With what is shigella diarrhea associated?
With reactive arthritis and daycare settings.
107
What is the cause of Yersinia diarrhea?
Rodent urine or feces and old creamy pastries.
108
What is important to keep in mind about Yersinia diarrhea?
RLQ pain mimicking appendicitis.
109
What is the cause of V.parahemolyticus diarrhea?
Undercooked seafood, usually oysters.
110
What are the features of V.parahemolyticus diarrhea?
Look for oysters eaten in warm weather environments.
111
What is the cause of Giardia diarrhea?
1. Drinking fresh water
| 2. Detected with 3 O&P studies or 1 ELISA antigen
112
How do we treat Giardia?
With metronidazole.
113
What is a possible complication of Giardia diarrhea?
Liver abscesses.
114
What is the cause of E.histolytica diarrhea?
Travelers in endemic areas.
115
Mention some causes of Non-bloody diarrhea?
1. Viral gastroenteritis
2. S.aureus
3. Tropheryma whippelii
4. Strongyloides
5. B.cereus
6. Scombroid food poisoning
7. Cryptosporidiosis
8. VIPoma/ glucagonoma and Zollinger-Ellison syndrome
116
What is the cause of viral gastroenteritis?
1. Rotavirus --> Daycare setting
| 2. Norwalk (Noro) virus --> Cruise ship gastroenteritis
117
What is the feature of viral gastroenteritis?
Self-limiting.
118
What is the cause of S.aureus diarrhea?
Creamy foods such as mayonnaise.
119
What are the features of S.aureus diarrhea?
Vomiting and diarrhea within 6-8 hrs of ingestion due to toxin.
120
What is the cause of Tropheryma whippelii diarrhea?
UNKNOWN reservoir.
121
How do we diagnose Tropheryma whippelii?
EGD biopsy shows PAS-positive macrophages.
122
What is the treatment for Tropheryma whippelii?
Antibiotics for 1 year or more.
123
What is the cause of Strongyloides diarrhea?
Ascends through the skin of the foot to the lung, and then is shallowed.
124
What are the features of Strongyloides diarrhea?
1. Diarrhea
2. Epigastric pain
3. Anemia
4. Eosinophilia
125
What is the treatment for Strongyloides?
Ivermectin or thiobendazole.
126
What is the cause of B.cereus diarrhea?
Refried rice.
127
What happens with B.cereus diarrhea?
Nausea and vomiting within 2 hours of ingestion.
128
What is the cause of Scombroid food poisoning?
1. Tuna
2. Mackerel
3. Mahi-Mahi
129
What happens with Scombroid food poisoning?
Diarrhea within 10 minutes of ingestion.
130
How do we treat Scombroid food poisoning?
With antihistamines.
131
Which is the MC GI disorder affecting Americans?
Esophageal disease --> 44% of population suffering from "heartburn" at least once a month.
