MKSAP GI Flashcards
What are the 3 diagnostic criteria for eosinophilic esophagitis? What is seen on EGD? What is the treatment?
- Dysphagia, biopsies w/ >15 eosinophils/hpf, and exclusion of other causes of eosinophilia
- Rings, longitudinal furrows, luminal narrowing, white exudates and plaques
- PPI or swallowed topical steroids (fluticasone or budesonide)
What can be used to relieve chest pain in diffuse esophageal spasm? Dysphagia?
- Trazodone, Imipramine, or Sildafenil
2. Calcium channel blockers
What is the approach for indefinite dysplasia when screening for barrett esophagus? Low grade dysplasia?
- Start PPI and repeat EGD in 3-6 months; if still present repeat EGD in 1 year
- Endoscopic therapy
What study is used to evaluate oropharyngeal dysphagia?
Videofluroscopy
What is the test to perform for GERD sx refractory to empiric PPI therapy?
EGD. If normal then ambulatory esophageal pH monitoring
What is the management for a young adult with dyspepsia?
H. pylori testing -> 4 week trial PPI -> EGD
What are the two diagnostic criteria for post-prandial distress syndrome? What is the treatment? What is the treatment for epigastric pain syndrome?
- Bothersome post-prandial fullness and early satiety (at least 3 days a week)
- Metoclopramide, Buspirone -> if no relief of sx can use TCAs or mirtazapine
- PPIs or H2 blockers -> if no relief can use TCAs or mirtazapine
What is the 3 treatment regimens for H. pylori? What is the regimen for failure of bismuth or clarithromycin based therapy?
- PPI + Clarithromycin + Amoxicillin
- PPI + Clarithromycin + Metronidazole (if penicillin allergy)
- PPI + Bismuth + Tetracycline + Metronidazole (penicillin allergy, previous macrolide exposure)
* PPI + Levofloxacin + Amoxicillin
What are the two causes of atrophic gastritis? Which has higher risk of gastric ulcers and gastric cancer? Which increases risk of gastric carcinoid tumors due to increased gastrin?
- H. pylori and autoimmune
- Environmental gastritis is more common in antrum and has higher risk of gastric ulcers & gastric cancer;
Autoimmune gastritis is associated w/ gastric carcinoid tumors (pH >5 unlike in Zollinger-Ellison syndrome)
What are causes of gastroparesis? Name at least 6.
Diabetes, post-surgical, post-viral, hypothyroidism, amyloidosis, connective tissue disease, paraneoplastic syndrome, opioids, eating disorders
What kind of gastric polyp can be seen with PPI use? At what size should hyperplastic polyps in the stomach be removed?
- Fundic gland polyp
2. >0.5 cm
What are the sx of early dumping syndrome? Late dumping syndrome? How do you make the diagnosis?
- Palpitations, flushing or pallor, diaphoresis, LH, hypotension, and fatigue followed by diarrhea, nausea, abdominal pain, cramping, and bloating; occurs within 30 min of eating
- Decreased concentration, faintness, and altered consciousness; occurs 1-3 hours after meals
- Oral glucose challenge testing
What test can be used to check pancreatic exocrine function?
Fecal elastase
What is the diagnostic imaging criteria for type 1 autoimmune pancreatitis? What else is seen in type 1 AIP (name at least 3 conditions)? What is the difference between type 1 & type 2 AIP?
- Narrowed main pancreatic duct, and parenchymal swelling (sausage-shaped pancreas)
- PSC, bile duct strictures, Sjogrens, interstitial nephritis, autoimmune thyroiditis
- Type 2 will not have IgG4 positive cells in pancreatic tissue, and rather has neutrophilic infiltration; has occasional association w/ ulcerative colitis
What are 2 syndromes and 1 germline mutation associated with pancreatic cancer?
Peutz-Jegher syndrome, Lynch syndrome
BRCA2 mutation
Besides the colon and rectum, where else in the GI tract are patients w/ FAP at higher risk for developing cancer? What screening should they get and when should it start?
Peri-ampullary region of pancreas - they develop adenocarcinoma
EGD should start at age 25-30 or at the time of onset of colonic polyps (whichever is first)
What are high risk features of pancreatic cysts? What lab is elevated in pseudocysts?
Involvement/dilation of main pancreatic duct, size >3 cm, symptomatic, solid component
Amylase is elevated pseudocysts
What pancreatic cystic lesion is typically seen in women? Where is it usually located? What lab is elevated?
Mucinous cystic neoplasm
Pancreatic body or tail
CEA is elevated
What are examples of medications that can cause pancreatitis? Name at least 7.
Furosemide, HCTZ, Simvastatin Mesalamine, 6-MP, azathioprine Didanosine Asparaginase, valproic acid Sulfonamides, estrogen
What are the 6 categories of chronic diarrhea?
Osmotic, Secretory, Steatorrhea, Inflammatory, Motility, Miscellaneous
How do you calculate stool osmotic gap? What is the osmotic gap in secretory diarrhea? Osmotic diarrhea?
290 - (2 x [stool sodium + stool potassium])
<50 mmol/kg
>100 mmol/kg
What antibody can be checked in celiac disease if patient has IgA deficiency?
Anti-deaminated gliadin peptide IgG antibodies
What should be done to confirm response to therapy in patients w/ celiac disease? When should patients have a DEXA scan?
- Antibody testing 6-12 months after diagnosis, then annually
- At time of diagnosis
What is the medication treatment for short bowel syndrome?
Glucagon-like peptide 2 and its analog, teduglutide
What immunomodulators are used in UC? What labs should be checked routinely, and what genotype should be checked? What immunomodulator is used in Crohn’s?
- Azathioprine, 6-MP
- CBC, LFTs; TMPT mutation
- Methotrexate
What is the minimum time frame that latent TB need be treated before starting anti-TNF therapy?
2 months
What are natalizumab, vedolizumab, and ustekinumab used for?
Natalizumab, Vedolizumab, and Ustekinumab are used in Crohns disease
Vedolizumab can be used in UC
What cancer screening should women w/ IBD undergo annually?
Pap testing since they are at a higher risk for cervical dysplasia
When should screening colonoscopies start in patients w/ IBD?
8 years after diagnosis, then every 1-2 years
At the time of diagnosis if they have PSC
Can consider starting 15 years after diagnosis if only left-sided colitis
What medications can cause microscopic colitis? What is the treatment?
NSAIDs, SSRIs, and PPIs
Loperamide -> Oral budesonide
What is the diagnostic criteria for IBS?
Abdominal pain at least 1 day a week for 3 months along with at least 2 of the following 3: pain related to defecation, change in stool frequency, or change in stool consistency
What are the two therapies recommended by AGA for IBS-C? What are the 3 FDA-approved medications for IBS-D?
- Linaclotide, Lubiprostone
2. Rifaximin (14 day course), Eluxadoline, Alosetron
What is Eluxadoline used for? What are the contraindications? Name 5.
IBS-D
Pts w/o a gallbladder, those w/ suspected biliary obstruction, sphincter of oddi dysfunction, >3 alcoholic beverages daily, hx of pancreatitis, severe hepatic impairment, or hx of severe constipation
What is the test of choice for colonic ischemia?
Colonoscopy w/ biopsies
Can do non-invasive imaging of vasculature if right-sided ischemia to exclude occlusive process of SMA
What is staging of anal cancer based on?
Tumor size
Only cancers involving the vagina, urethra, or bladder are T4 lesions, regardless of size
If factitious diarrhea is suspected what does measured stool osmolality <250 mOsm/kg H2O suggest? Osmolality >400? Osmolality 250-400 with osmotic gap <75? Osmolality 250-400 with osmotic gap >75?
- Adding water to stool
- Adding urine to stool (so need to measure urea and creatinine)
- Secretory laxative use (saline, senna, bisacodyl)
- Ingestion of lactulose, sorbitol, mineral oil, magnesium sulfate, polyethylene glycol
What diagnosis should be considered in patients w/ diarrhea (can be nocturnal) and diabetes or scleroderma?
SIBO
What diagnosis should be considered w/ resection of <100 cm of distal ileum, and voluminous diarrhea, weight loss, and malnutrition? How is it treated?
Short bowel syndrome with bile acid enteropathy
Cholestyramine
*Do not use if ileal resection >100 cm
What laxative can lead to benign pigmentation of the colon? What is this known as?
Senna (chronic use)
Melanosis coli
What is Alosetron used for? What are the main side effects?
IBS-D in women age >18
Ischemic colitis and severe constipation
When should you start screening for CRC in patients w/ fam hx?
Patients with first degree relative diagnosed w/ CRC <60 y.o. or two or more first degree relatives at any age diagnosed with CRC
Start screening at age 40 or 10 years earlier than age of youngest FDR at diagnosis; repeat every 5 years
When should you start screening for CRC in Lynch syndrome? When should total hysterectomy and bilateral SPO be considered in Lynch syndrome? When should CRC screening start in FAP?
- 20-25 years or 2-5 years earlier than youngest cancer in family; repeat every 1-2 years
- Age 40-45
- 10-12 years; repeat every 1-2 years
When should you repeat a colonoscopy if there are 1-2 tubular adenomas <1 cm in size? 3-10 adenomas, adenoma >1 cm, adenoma with villous features or high grade dysplasia? >10 adenomas?
- 5 years
- 3 years
- <3 years, and a genetic cause should be investigated
When should you repeat a colonoscopy in a patient w/ serrated polyps that are <10 mm in size? Any sessile serrated polyp >10 mm in size, 5-10 sessile serrated polyps <10 mm, or has dysplasia? Traditional serrated adenomas? Serrated polyposis syndrome?
- 5 years
- 3 years
- 3 years
- 1 year
What syndrome is associated w/ mutations in mismatch repair genes (MLH1, MSH2, MSH6, PMS2) or epithelial cell adhesion molecule gene (EPCAM)?
Lynch syndrome
When should screening w/ EGD start in patients w/ FAP? Lynch syndrome? How often should patients w/ FAP get a thyroid U/S?
- Age 25-30
- Age 30-35
- Annually - due to risk of papillary thyroid cancer
When should you repeat a colonoscopy in a patient w/ rectosigmoid hyperplastic polyps <10 mm in size?
10 years
What patients typically have the immune-tolerant phase of hepatitis B? When do they require treatment?
Patients who acquired HBV through vertical transmission - remains for first 2-3 decades
Treat if patients >40 y.o. w/ HBV DNA level and least 1 million IU/mL and significant inflammation/fibrosis
What is the immune active phase of HBV? What is the immune control (inactive) phase?
- Intermittently or persistently elevated ALT (>2 x ULN), HBV DNA at least 20,000 in HBeAg-positive disease (most common) and greater than 2,000 IU/mL in HBeAg-negative disease; Treatment is warranted
- Loss of HBeAg and development of anti-HBe; ALT must be normal and HBV DNA level <2000 IU/mL when measured every 3-4 months for 1 year; 10% of patients spontaneously convert to this each year
Which patients have HBsAg? When should prophylactic oral anti-viral therapy be given to HBsAg-positive patients?
- Those w/ acute infection, immune control (inactive), and immune active infection
- Receiving B cell depleting therapy (rituximab), prednisone >10 mg/day for 4 weeks, anthracycline derivatives, TNF-alpha inhibitors, tyrosine kinase inhibitors
When can pegylated interferon be used for hepatitis B treatment?
High ALT levels, low HBV DNA levels, no cirrhosis, not pregnant, no psychiatric disease, no cardiac disease, no seizures, no cytopenia, and no autoimmune disease
What are the tx goals for HBeAg-positive, immune active phase? How long should they be treated?
What are the tx goals for HBeAg-negative, reactivation phase? How long should they be treated?
- HBeAg loss and anti-HBe seroconversion; this should be followed by additional 12 months treatment
- HBV DNA suppression and ALT normalization; continue oral anti-viral agents indefinitely
What is the treatment for hepatitis D w/ evidence of progressive liver disease?
Pegylated interferon for 12 months
What is the treatment for autoimmune hepatitis?
Prednisone and Azathioprine, for 2-3 years
What is used to calculate the Maddrey’s score? At what score should steroids be used? What are the contraindications to steroid use in alcoholc hepatitis?
- PT and total bilirubin
- Score >32 indicates poor prognosis and use of steroids; Also treat if MELD >18, or encephalopathy + ascites
- Contraindications: active infection, upper GI bleeding, AKI, concmitant liver disease (especially HCV & HBV), multiorgan failure
What is the Lille score used for?
Response to steroids after 7 days in patients w/ alcoholic hepatitis; should be dc/ed if no response (score >0.45), and continued for 28 days if <0.45
What is the treatment for Amanita mushroom poisoning?
Penicillin G or silymarin
What are the two treatment options for Wilsons disease? What supplements can be given to decrease the intestinal absorption of copper?
- Trientine, Penicillamine
2. Zinc
Deficiency in long-chain 3-hydroxyacyl CoA dehydrogenase deficiency is associated w/ what condition?
Acute fatty liver of pregnancy
Affected women and their offspring should be screened
When should hepatitis B positive pregnant patients start treatment? What 3 options are available?
HBV DNA >200,000 IU/mL between weeks 24-28
Lamivudine, Tenofovir, Telbivudine
Which liver mass have the potential for malignant transformation - hepatic adenoma, focal nodular hyperplasia, hepatic hemangioma?
Hepatic adenoma - lesions <5 cm should get imaging every 6 months for 2 years; those >5 cm, causing sx, or in males should get resected; stop OCPs
Patients w/ HBV can develop HCC w/o cirrhosis. Which high risk patients should be screened with U/S every 6 months?
Sub-saharan Africans >20 y.o., Asian men >40 y.o., Asian women >50 y.o., elevated ALT level and HBV DNA levels >10K for a few years, family hx of HCC
What is the Milan criteria for liver transplantation in patients w/ cirrhosis and HCC?
Patients w/ portal HTN or jaundice, and up to 3 liver lesions 3 cm in size or less, one lesion 5 cm in size or less, without macrovascular invasion and without extraheptic spread
Besides HCC, what should patients w/ cirrhosis get screened for?
Osteoporosis
What are the 2 PBC-specific autoantibodies?
sp100 and gp210
What cancer should patients w/ PSC be screened for and how often?
Cholangiocarcinoma w/ CA 19-9 and U/S, or MRCP; every 6-12 months
Colonoscopy at time of diagnosis
What is Child-Pugh score used for? What is the criteria that is used?
Prognosis in cirrhosis - 1 and 2 year mortality; originally used for peri-operative mortality
Albumin, Bilirubin, Coagulation (INR), Drum abdomen (ascites), Encephalopathy
When should nonselective B-blocker therapy be started for esophageal varices?
Small varices w/ red wale marks
If small varices < 5 mm, repeat EGD in 2 years
If no varices repeat EGD in 3 years
When should patients w/ SBP get albumin, and what is the dose?
Cr >1, BUN >30, or total bilirubin >4
1.5 g/kg on day 1, 1 g/kg on day 3
What are the indications for SBP prophylaxis?
A. Hx of SBP
B. cirrhosis + GIB
C. Ascitic fluid protein <1
D. Ascitic fluid protein <1.5 g/dL + impaired renal function (BUN >25, Cr >1.2, Na <130) or liver failure (Child Pugh score >9 and bilirubin >3)
What is the albumin dose for hepatorenal syndrome?
1 g/kg x 2 days
What is the radiologic criteria for HCC diagnosis?
Lesions >1 cm that enhance in the arterial phase and have washout of contrast in the venous phase
What medication is used for advanced HCC?
Sorafenib
What is the vaccine schedule for hepatitis A?
What is the post-exposure prophylaxis for hepatitis A?
- 1 dose, then 2nd dose 6-12 months later; + serum immune globulin for immunocompromised and those w/ chronic liver disease
- Vaccine within 2 weeks; Consider immunoglobulin in those age >40, immunocompromised, and those w/ chronic liver disease
What is the first test to perform if considering hemochromatosis? What is the targeted serum ferritin level w/ treatment? What additional workup is needed if ferritin >1000 or LCTs are elevated?
- Serum transferrin > 50-55%
- Ferritin <50
- Liver biopsy to stage hepatic fibrosis
What is the gallbladder ejection fraction in functional gallbladder disorders?
<40%
Can do cholecystectomy if no other cause of pain is found
Within what time frame should cholecystectomy be performed after cholangitis w/ stone removal?
2 weeks
What is the management for gallbladder polyp <5 mm? 6-9 mm? >1 cm? Any size + gallstones or biliary colic? >8 mm + PSC? Asymptomatic gallstone >3 cm?
- Repeat U/S in 12 months, perform cholecystectomy if increase in size
- Repeat U/S in 6 months then yearly
- Cholecystectomy
- Cholecystectomy
- Cholecystectomy
- Prophylactic cholecystectomy
What should an older adult, immunocompromised pt, and pt w/ chronic liver dz do re hepatitis A if traveling in <2 weeks?
Receive one dose of vaccine + immune globulin
When should steroids not be used in alcohol hepatitis?
Infection, AKI, GI bleeding, pancreatitis
What are the two most common causes of AIDS cholangiopathy?
Cryptosporidium and CMV
What are the differences between HELLP and acute fatty liver of pregnancy?
HELLP is more associated w/ MAHA
AFLP is more associated w/ encephalopathy and coagulation abnormalities
What is Mirizzi syndrome?
Obstructed common hepatic duct caused by extrinsic compression by impacted gallstone in cystic duct
What diagnosis is considered in a young pt w/ painless hematochezia and normal EGD + colonoscopy?
Meckel diverticulum
What medication can decrease risk of progression of biliary colic?
NSAIDs
What is the treatment for simple, asymptomatic perianal fistulas in Crohn’s disease? What is the management for moderate-severe sx?
- Metronidazole or Ciprofloxacin
2. Infliximab (preferred) or azathioprine, 6-MP, or tacrolimus; if not resolved can do surgery
How do you diagnose chronic mesenteric ischemia?
MR or CT angiography
What is the treatment for campylobacter? Shigella? Salmonella? Vibrio?
- Azithromycin
- FQN or azithromycin if severe illness
- FQN +/- CTX if severe illness; azithromycin is alternative for mild illness
- FQN or Azithromycin
What is the treatment for E. histolytica?
Metronidazole, then Paromomycin or Iodoquinol to eradicate intestinal reservoirs
What does 75SeHCAT testing or fasting serum C4 (7a hydroxy-4-cholesten-3-one) test for?
Bile acid diarrhea
Tx is bile acid binder
What are the 3 options to treat opioid-induced constipation?
Naloxegol, Methylnaltrexone, Naldemedine
What medications should be discontinued in patients with ascites?
NSAIDs, ACEi/ARBs
What medication can lead to sprue-like enteropathy that mimics celiac disease with villous atrophy and intraepithelial lymphocytes in the duodenum?
Olmesartan; some other ACEis can cause this as well
What are the 2 first line treatments for hepatitis B?
Entecavir, Tenofovir
What is the surveillance regimen after treatment for colon cancer?
Surveillance colonoscopy 1 year after diagnosis, then in 3 years if normal (per AGA); if normal repeat every 5 years
Annual CT chest/abdomen/pelvis for 5 years after resection
CEA every 3-6 months for 2 years, then every 6 months for 5 years
What is the management for uncomplicated sigmoid volvulus?
Sigmoidoscopy to untwist the volvulus, restore blood supply, and assess colonic viability
What is the management for intrahepatic cholestasis of pregnancy?
Ursodeoxycholic acid
Delivery at 36 weeks gestation
Name 2 pathogens associated w/ colonic malignancy
Strep gallolyticus
Clostridium septicum
What is the management for a liver nodule?
If <1 cm repeat U/S in 3 months
If >1 cm obtain MRI w/ contrast (or MDCT)
What is the management of suspected gastrinoma?
Check gastrin levels - if less than 110, negative; if >1000 positive and need to check pH (if <4 is diagnostic); if 110-1000 do secretin stimulation test (gastrin will increase significantly after secretin is given)
What presents w/ malaise, fever, lymphadenopathy, symmetric polyarthralgia/arthritis, and urticarial rash?
Serum sickness-like reaction with acute hepatitis B
What has enlargement of gastric folds in the fundus and presents w/ epigastric pain, nausea, vomiting, diarrhea, edema due to hypoalbuminemia, and significant weight loss? What is the treatment?
- Menetrier’s disease
2. Cetuximab
What test should be performed after a diagnosis of pernicious anemia?
EGD
Who should be screened for barrett’s esophagus?
Men age >50 with GERD for >5 years and at least one additional risk factor (smoking, elevated BMI, intra-abdominal distribution of body fat, nocturnal reflux sx, hiatal hernia)
What is the management for GIST?
Surgery if symptomatic, size >2 cm, lobulated or irregular borders, invasion into adjacent structures, and heterogeneity
When should acute hepatitis B be treated?
Acute liver failure, >4 weeks of symptoms with significant jaundice (bilirubin >10), immune active phase, reactivated disease, cirrhosis
What cancers can be found in Lynch syndrome? Name 6.
Colorectal, endometrial, stomach, ovary, hepatobiliary, urinary tract, small bowel, brain, pancreas, skin
What mutation is found in Peutz Jegher syndrome? What cancers is it associated with? Name 6.
- STK11 gene
2. Colon, small bowel, stomach, breast, ovary, cervix, uterus, lung, and pancreas
Cowden syndrome is associated with GI hamartomas. What mutation is found? What cancers is it associated with? Name 3.
- PTEN gene
- Colon, breast, thyroid, kidney
Also associated w/ macrocephaly and dermatologic manifestations (trichilemmoma)
Which patients should receive hepatitis B anti-viral therapy indefinitely?
Those who were in the reactivation phase, and those with cirrhosis
What should be tried after lifestyle changes for chronic, slow-transit constipation?
Bulk-forming laxatives
Does ASA need to be held before colonoscopy w/ polypectomy?
No
How do you evaluate a suspected aorto-enteric fistula?
CT w/ contrast
What are the differences between inflammatory diarrhea (campylobacter, shigella, salmonella) and non-inflammatory (clostridium perfringens, ETEC) regarding volume of diarrhea and sx of abdominal pain?
Inflammatory affects the large bowel so results in crampy abdominal pain and frequent small-volume diarrhea; blood and mucus may be present
Non-inflammatory affects the small bowel and results in large-volume watery diarrhea w/ or w/o N/V, abdominal cramps
What is one way to decrease fat malabsorption in a patient that is post-whipple/with pancreatic insufficiency and taking pancreatic enzymes?
Add PPI and encapsulate the pancreatic enzymes
