Mixed Flashcards
Normal stool fat content
< 14 g/day
14-20: investigate small bowel causes
>20: investigate pancreatic causes
Indications to pursue stool micro studies
Fever >38.5
bloody stools
high stool WBC
elderly aged 70 and above
ICC state
Duration >48 hours without improvement
Recent antibiotic use
New community outbreak
Associated severe abdominal pain in patients >50 years
INDICATED TO GIVE ANTIBIOTIC TREATMENT FOR ACUTE DIARRHEA
- Immunocompromised
- (+) mechanical heart valves or recent vascular grafts
- Elderly
INDICATION TO GIVE ANTIBIOTIC PROPHYLAXIS for Diarrhea
“GIIH”
- Immunocompromised**
- IBD**
- Hemochromatosis**
- Gastric achlorhydria**
DOC for diabetic diarrhea
Clonidine
Drug for diarrhea in IBS
5 HT3 antagonist (Ondansetron)
Treatment of diarrhea associated with IBS
5 HT3 antagonist (Ondansetron)
Rifaximin
eluxadoline (κ-OR agonist and δ-OR antagonist)
What 3 conditions would make colonoscopy among < 40 years old preferable than flexible sigmoidoscopy?
-Copious bleeding
-Family hx of colon CA
-IDA
Conditions with SAAG < 1.1
“Bili Neph Peri Tub”
Biliary Leak
Nephrotic Syndrome
Peritoneal carcinomatosis
Pancreatitis
Tuberculosis
Conditions with SAAG >= 1.1 with Ascitic protein < 2.5
“C LB M”
Cirrhosis
Late Budd Chiari
Massive liver mets
Conditions when abx prophy needed for GI procedures
ERCP
-Sterile pancreatic fluid collection*
-Bile duct obstruction ⊖ cholangitis (with expected incomplete drainage)*
EUS FNA
-Cyst along GI, pancreas, mediastinum
PEG
Cirrhosis with GI bleed
Continuous PD
Transmural drainiage
-Sterile pancreatic collection
*continue after procedure
Types of gastritis and their level of acid production
Type I - body; low
II- antrum; normal to low
III- pylorus with DU; normal to high
IV - cardia; low
Nutrition deficient with long term PPI use
Iron
Magnesium
Vit B12
Chronic gastritis types and features
Type A - Autoimmune
Type B
-antral
-assoc with adenocarcinoma
-aging
What stage of hemorrhoids are the following initially indicated?
RBL
Sclerotherapy
Sclerotherapy - II
RBL - III
GERD Warning Signs
Dysphagia/Odynophagia
Recurrent vomiting
GI bleed
Jaundice
Weight loss
Palpable adenopathy or mass
Familial hx of GI malignancy
Antibiotic coverage is required in these patients who present with acute diarrhea, whether or not a causative organism is discovered
“I love old ppl”
ICC state
Mechanical heart valves
Elderly
Most consistent clinical feature in IBS
Alteration in bowel habits
Percutaneous drainage in Hinchey II is highly recommended with what abscess size?
> 3cm
< 5cm may resolve with abx alone
What 2 conditions are contraindications to hemorrhoid procedures?
1) ICC state
2) Proctitis
Which of the following is the most common cause of functional bowel obstruction?
Intaabdominal surgery
Acetaminophen blood level correlated with severe hepatic damage?
> 300 ug/mL 4hr
< 150 ug/mL - unlikely
Risk factors for progression to advanced liver fibrosis to those with NASH
Age > 45-50
Overweight/obese
T2DM
3 recommendations for cholecystectomy
1) symptomatic
2) prior history of gallstone disease
3) calcified GB/porcelain gallbladder
Diagnostic algorithm for chronic pancreatitis
CT
MRI
EUTZ
Pancreas function test
ERCP
Most prevalent cause of drug induced acute liver failure?
Acetaminophen
The most common agent implicated as causing drug-induced liver injury
Co-Amoxiclav
Drugs with mild, transient, nonprogressive serum aminotransferase elevations that resolve with continued drug use
VIPS
Valproate
Isoniazid
Phenytoin
Statin
Most common pattern of liver injury
Hepatocellular injury
Pathologic findings in hepatocellular injury
Spotty necrosis in the liver lobule with a predominantly lymphocytic infiltrate resembling that observed in acute hepatitis A, B, or C
Pathophysiology of cholestasis
Binding of drugs to canalicular membrane transporters, accumulation of toxic bile acids resulting from canalicular pump failure, or genetic defects in canalicular transporter proteins
R values and corresponding type of liver pattern injury
- R value of >5 → HEPATOCELLULAR INJURY
- R value of <2 → CHOLESTATIC INJURY
- R value of 2.0 - 5.0 → MIXED HEPATOCELLULAR-CHOLESTATIC INJURY
Pathology in acetominophen liver injury
Dose related centrilobular necrosis
Laboratory findings in hyperacute acetaminophen injury
Very high ALT
Low bilirubin
Symptomatic phase –> clinical resolution –> markers deranged 3-5 days post ingestion
What acetaminophen levels will administration of N-acetylcysteine reduce the severity of hepatic necrosis?
> 200 μg/mL measured at 4 h or >100 μg/mL at 8 h after ingestion
Time frame when there is benefit of charcoal or cholysteramine in Acetaminophen induced liver injury
Within 30 mins
Recommended time to measure acetaminophen levels
8 hours post ingestion
NAC recommended time for treatment administration
Within 8 hours; 24-36 hrs latest
Which viral hepatitis is more predisposed to DILI?
Hepatitis C
Pathophysiology involved in sodium valproate hepatotoxicity
Microvesicular fat and bridging hepatic necrosis, predominantly in the centrilobular zone
DOC for amelioration of sodium valproate
Carnitine
“Vanishing bile duct syndrome”
Co-amoxiclav
Mixed pattern or cholestatic
Drug known to present as SJS and have eosinophils in the liver
Phenytoin
-Idiosyncratic
-2 months after ingestion
Drug known to present as SJS and have eosinophils in the liver
Phenytoin
-Idiosyncratic
-2 months after ingestion
Amiodarone toxicity - direct or idiosyncratic
Direct
Which of the following is a highly sensitive and specific marker for detecting intestinal inflammation?
Fecal lactoferrin
Which of the following markers correlate well with histologic inflammation, predict relapses and detect pouchtitis in patients with Ulcerative Colitis?
Fecal calprotectin
Smoking prevents disease in which type of IBD?
UC
Appendectomy is protective in which IBD?
UC
No increased risk of what type of IBD when it comes to OCPs?
UC
Greater genetic concordance in which type of IBD?
Crohn’s
Early onset IBD is associated with deficiency in what inflammatory marker?
IL-10
Early onset IBD is associated with deficiency in what inflammatory marker?
IL-10
Which IBD for the ff conditions:
-Gross blood in stool
-Mucus
-Pain
-Systemic symptoms
-Fistulas
-SI obstruction
-Colonic obstruction
-With response to abx
-With recurrence even after surgery
-Continuous disease
-Rectal sparing
-Cobblestoning
-Granuloma on biopsy
-Strictures
-Abnormal imaging findings
-limited to mucosa and superficial submucosa
-Gross blood in stool: UC
-Mucus: UC
-Pain: Crohns
-Systemic symptoms: Crohns
-Fistulas: Crohns
-SI obstruction: Crohns
-Colonic obstruction: Crohns
-With response to abx: Crohns
-With recurrence even after surgery: Crohns
-Continuous disease: UC
-Rectal sparing: Crohns
-Cobblestoning: Crohns
-Granuloma on biopsy:Crohns
-Strictures: Crohns
-Abnormal imaging findings: Crohns
-limited to mucosa and superficial submucosa, with deeper layers unaffected except in fulminant disease: UC
Chronic UC/Crohns leads to development of what structure?
Pseudopolyps
Complications of UC
- Bleeding
- Toxic Megacolon
- Strictures
- Anal fissures
- Perianal abscess
- Hemorrhoids
Indications for Surgery in UC
- Need 6-8 units prbc within 24-48 hrs
- right colon and transverse colon with diameter of > 6cm and loss of haustrations
- Strictures necessitating endoscope for dilation
Most serious complication of UC
Perforation
Pathologic feature of Crohns?
Noncaseating granulomas in all walls
Submucosal or subserosal lymphoid aggregates
What symptom is characteristic of active disease in IBD?
Diarrhea
2 patterns of disease in Crohns
- Fibrostenotic obstructing pattern**
- Penetrating fistulous pattern**
Type of gastritis in Crohns patients
H pylori negative gastritis
Earliest macroscopic findings in Crohns
Apthous ulcerations
Size when endoscopy is preferred for stricture
<= 4cm
Antibodies associated with CD
anti-Saccharomyces cerevisiae antibodies (ASCAs)
Immunologic marker for UC
pANCA
CLINICAL FACTORS AT DIAGNOSIS THAT PREDICT THE NATURAL HISTORY OF DISABLING CROHN’S DISEASE AFTER 5 YEARS
- Initial requirement of steroids
- Age at diagnosis below 40 years
- Presence of perianal disease at diagnosis
Tx of choice
Mild UC
Mod-Severe UC and Crohns
Mild UC: 5-ASA
Mod-Severe UC and Crohns: Prednisone or Biologics (-mab, MTX, Cyclosporine, Tacrolimus)
Indication for annual or biennial colonoscopy with multiple biopsies in UC
8-10 years of extensive colitis (>1/3 of colon involved) OR
12-15 years of proctosigmoiditis (<1/3 but more than just the rectum)
Management of Flat high and flat low dysplasia
Flat high dysplasia: Colectomy
Flat low dysplasia: Immediate colectomy
Which of the following HLA alleles has been linked with self-limited hepatitis C?
CC haplotype of the IL28B gene
Which of the following antiviral medications can be safely given during pregnancy?
Tenofovir
Lamivudine
Favorable factor that may determine sustained virologic responsiveness in Hep C?
Female
Which of the following drug should not be given with amiodarone?
Sofobir
Indications for treatment of chronic hepatitis in pregnancy
HBV DNA >200,000 IU/mL
Third trimester Pregnancy
First line treatment for chronic Hep B
Tenofovir
Side effects of Tenofovir and Entecavir
Tenofovir disoproxil fumarate - renal toxicity; loss of bone density
Entecavir - prone to resistance
Which Oral nucleotide analogs is safe to use during pregnancy
Tenofovir
Duration of treatment for HBeAg positive and negative chronic hepatitis
HBeAg +, non cirrhotic: for 12 months
*monitor monthly for 6 months then q3 months for 1 yr
HBeAg -: indefinitely or unti HBsAg disappears
DOC for Chronic Hepatitis C
SOFOSBUVIR + VELPATASVIR
Definition of sustained virologic response for Hep C
Undetectable HCV RNA 12 weeks after completion of treatment
DOC for Chronic Hepatitis D
PEG-IFN(for 48 weeks)
Difference in Type I VS Type II AIH
young women - children
ANA + (homogeneous)
pANCA - Anti LKM
Marked hyperglobuliemia and lupoid features - anti liver cytosol
Therapy for AIH
-Combination therapy (Azathioprine 50 mg/d + Prednisone 30 mg/d)
- High dose prednisone (60 mg/d) therapy is preferred
Duration of Tx: 12-18 months
Histo improvement: 6-24 months
DOC for decompesated/relapsed chronic hep c?
Ribavarin
Single most important measurement of hepatic synthetic measure for acute parenchymal disease
Clotting factors -
Serum prothrombin II V VII X
Hydration for acute pancreatitis
15-20 mL/kg/hr, maintain at 2-3cc/hr to maintain UO >0.5mL/kghr
Mainstain of autoimmune hepatitis
Glucocorticoid
First-line pharmacotherapy for non-diabetic NASH patients
Vitamin E
What are considered low risk endoscopic procedures?
EGD/colo
EUS without FNA
ERCP for stent replacement
Components of grade III cholangitis
Hypotension
PFR <300
Oliguria, crea >2 mg/dL
Plt <100
INR >1.5
Indications for cholecystectomy for GB POLYP
1 age > 50
Polyp > 10 mm
Growth in polyp size on UTZ
