MKSAP17 Flashcards
What is the name of the classification system that grades peptic ulcers and identifies mortality rates and guides tx?
Forrest Classification
Best mgmt of pt with Barret Esophagus without dysplasia –1) medications 2) follow up
PPI for indeterminate period of time; EGD q 3-5 years
Patients with moderate to severe UC who do not respond to oral glucocorticoids should receive what agents
IV steroids or Anti-TNF (one of Infliximab, adalimumab, or golimumab; certo is in Crohns, goli is not); watch for hx of CHF w/ TNF and watch for new drug induced SLE
In a patient who required steroids for a severe flare of UC and now has achieved “remission” what would your plan with steroids and new meds be moving forward?
Taper steroids slowly if concern for HPA axis (depends how long they have been on); Then add either a thiopurine (6-MP, azathioprine) assuming TPMT levels normal; or add TNF-A
What is the tx of typhlitis?
Neutropenic Enterocolitis; tx is with broad spec abs (Cefepime and Flagyl; Zosyn)
What is eosinophilic enteropathy?
An infiltrative enteropathy often presenting with chronic diarrhea and a Bx showing prominent eosinophilic infiltrate that can lead to protein losing enteropathy; treated with steroids
What is the most appropriate step after therapy for H. pylori is completed?
Check for eradication with either stool antigen or urea breath test
Metronidazole followed by oral paramomycin is indicated for the management of this bloody diarrhea
Entamoeba histolytica; Metronidazole first to kill the organism then paramomycin a luminal agent to kill cysts (also if use paramomycin upfront can cause bad diarrhea)
What is the main aspect of tx of porphyrea cutanea tarda?
Phlebotomy
The scoring system that tells you whether or not intervention is needed for suspected GIB and if it needs to be inpatient or outpatient is _________
Glasgow-Blatchford score
When is HCC screening indicated in patients with HBV?
Any HBV related cirrhosis; Asian men >40, Asian women >50 or anyone with FMHx of HCC; Abd US q6 months like usual
How long is antibiotic ppx continued for in patients with variceal hemorrhage?
Maximum of 7 days
What are two causes of villous atrophy in the duodenum?
Celiac Sprue and Tropical Sprue; Whipple’s will have PAS positive macrophages in the duodenum but not blunting; Crohn would cause neutrophilic infiltration rather than lymphocytic and no blunting
What cause of worsening colitis in IBD patients classically occurs with intensification of immunosuppresion?
CMV colitis would want to do flex sig and bx as a negative serum PCR does not exclude tissue invasive disease
What is the Maddrey Discriminant function equation?
Total Bilirubin + 4.6 (PT- lab reference of PT); more than 32 should give prednisolone or pentoxyfylline (acts on preventing TNF-A synthesis). Of note, if the t bili is in the 30s you should just treat
What is a typical liver profile in Wilson dz? Which transaminase tends to rise in biliary dz?
2:1 AST to ALT much higher than EtOH with relatively normal ALP; ALT first and if >200 think that could be cholangitis rather than just cholecystitis
How do you manage pt with low risk polyps on colonoscopy? What if they are large >10 mm, or dysplastic sessile serrated polyps?
Repeat colonoscopy in 5 years; if >10 mm or dysplastic sessile serrated polyps or traditional sessile serrated should do q3 years
What is the best mgmt for a pt with variceal hemorrhage who does not have ascites from an antibiotic standpoint?
Aside from tx as a UGIB and giving octreotide bolus and gtt in addition, would still give IV CTX for ppx; studies showed that the CTX was beneficial for infxn and mortality regardless of whether ascites present (i.e. not just “SBP” ppx)
Treatment of incidentally noted pancreas divisum?
No tx; if recurrent pancreatitis then consider
Oral Hairy Leukoplakia is due to _____
EBV
What HBV antigen is usually positive when chronic HBV starts to have inflammation?
HBeAg but not always (can be negative if PRECORE mutation is present)
When are sorafenib and TACE most used in HCC
Sorafenib is used for pts with vascular, lymphatic, or extrahepatic spread whereas TACE is more of a local therapy and used if not meeting Milan criteria for xplant or if they are expected to remain on the list for > 6 months
How does scleroderma affect the esophagus?
It causes smooth muscle atrophy and fibrosis of the distal esophagus; manometry often will show decreased peristalsis in the distal 2/3 of the esophagus
The findings of platypnea-orthodeoxia in a pt with cirrhosis raises concern for ______. Two diagnostic tests to elucidate?
Hepatopulmonary Syndrome (Gets MELD exception points, cure only with transplant); TTE with bubble to look for intrapulmonary shunt; VQ scan; Orthodeoxia = decrease in SaO2 by >5% when standing
Symptoms of flatulence, bloating, and diarrhea some time after a Roux-en-Y should be treated with __________
Empiric Abx (Rifaximin); this is likely SIBO; though a jejunal aspirate confirms the dx can give empiric abx
What type of medication can be started in patients with functional, nonulcer dyspepsia who are refractory to PPIs
TCAs (i.e. nonulcer dyspepsia means they have PUD like sx w/o an ulcer, different from GERD refractory to PPI)
Explain how CBD size changes with age?
Baseline normal diameter is 4 mm; but get 1 mm for every decade over 40
What dietary item is a common cause for diarrhea and sx of carbohydrate malabsorption?
Artificial Sweeteners; they are nonabsorbable sugar alcohols (Osmotic Gap would be >100) where osmotic gap = 290 - 2(Stool Na + Stool K)
What is Acrodermatitis Enteropathica-like syndrome? Where is it seen and why does it happen?
A vesiculobullous skin eruption that occurs in Crohn patients with Zinc def (also dysguesia); diff from dermatitis herpetiformis
What part of the stomach is atrophic in pernicious anemia?
Fundus = where parietal cells are housed and make acid (achlorhydria) and Intrinsic Factor (low B12)
What is the mgmt of Barret esophagus with high grade dysplasia? What about no dysplasia?
Endoscopic Ablation (RFA, Photodynamic Tx, or endoscopic mucosal resection-EMR; diff from Endoscopic Mucosal Dissection which dissects past the submucosa); Repeat EGD in 3-5 years
How should you evaluate new dysphagia in pt with known paraesophageal hernia?
EGD as the patient may have hernia torsion
What is the first line for candidal esophagitis? What about fungal pancreatitis?
PO fluconazole; An echinocandin; in pancreatitis there is lots of inflammation so the gut gets leaky and can seed the necrotic areas often with gut flora which includes fungus/Candida
What is the next best step for a rectal cancer that was discovered doing a flex sig or anoscopy?
Do a colonoscopy to rule out synchronous primaries so you can do the optimal surgery
What is the most effective way to decrease the risk of complications from acute gallstone pancreatitis?
ERCP with sphincterotomy in 24-72 hours; RCTs show lower risk of complications for pts who have this done in this timeframe
How do you manage dysphagia in pt with scleroderma? How is their presentation often different from achalasia?
Usually PPI and a prokinetic; scleroderma pts will also have reflux whereas achalasia usually does not
What medications are associated with induction of microscopic colitis?
NSAIDs and PPIs are big ones; the presentation is many episodes of watery diarrhea per day
A person with chronic HBV who has been vaccinated for HAV who presents with acute liver failure should prompt evaluation for what infectious agent?
HDV – the delta agent can only infect if already have HBV
How would you treat fulminant HBV infection i.e. with elevated transaminases PLUS hepatic encephalopathy and coagulopathy?
Without HE and coagulopathy can observe as most will clear; however, if fulminant liver failure then offer antivirals such as tenofovir or lamivudine, entacavir; of note though, you should associate antivirals more with chronic active HBV
A patient from South America who presents with malabsorption, negative celiac testing and findings of villous atrophy on EGD likely has ______
Tropical Sprue; tx is with tetracycline 250 mg qid for 3-6 months
What are some features of low risk hepatic adenomas and how are they managed?
<5 cm, occur in women on OCPs, and are + for HNF-1alpha; whereas B-catenin is high risk; low risk can get CT q6-12 mos
What is the optimal mgmt of mild acute cholecystitis?
Antibiotics and early laparascopic cholecystectomy i.e. within 72 hours if sicker get them in earlier (generally it is best to do in a day or so)
What disease classically has a SAAG <1.1 but a total protein >3
Tuberculous peritonitis; often has lymphocytic predominance; recall lymphocyte predominant effusions etc suggest chronic inflammation or cancer
Why should antibiotics generally be witheld in patients with acute necrotizing pancreatitis?
The original theory here (if >30% necrosis) was to start IV abx to prevent infection. The infection is due to leaky gut from all of the inflammation which ultimately leads to translocation and seeding. However, giving the abx only led to increased fungal infxn; if there is confirmed infected pancreatic necrosis as a late complication then give
What medication that is used for IBS-C acts on the CFTR channel?
Linaclotide
Most approprate mgmt of patient with toxic megacolon complicating refractory UC
Total colectomy with end ileostomy (surgical cure); usually >5.5 cm
What patients should be screened for esophageal varices?
Patients with signs of portal HTN (i.e. hepatosplenomegaly with spider angiomata, thrombocytopenia or pancytopenia not due to BM disorder); grade 2 or greater should get BB ppx
What should be considered in the ddx for a patient in the U.S. who has chronic diarrhea and exposure to young children?
Giardia lamblia (also increased risk if hypogammaglobulinemic esp. IgA; so also selective IgA def) tx is metro; also look for in ppl near lakes or streams
What is the deal with abx in acute necrotizing pancreatitis? When should they be added? What fungal coverage would you add and when?
Most pt with acute necrotizing pancreatitis will have SIRS and abx can actually increase risk of fungal infxn; If pt is getting better then gets worse would consider abx and scan and aspirate a lesion if concern for infected pancreatic necrosis; if still febrile on abx then add echinocandin to cover Candida another gut flora that translocates
What is the most likely dx for a young pt with megaloblastic anemia, abdominal pain and diarrhea with a palpable mass in the RLQ
Crohn dz with terminal ileitis; mass d/t phlegmon or stricture with proximal dilation; megaloblastic anemia due to inability to absorb B12
Lesions in what two parts of the GI tract can cause pernicious anemia?
Fundus of stomach where parietal cells are; terminal ileum where it is absorbed
List the Forrest Classification for PUD
1A = active spurting; 1B = active oozing; 2A = nonbleeding visible vessel; 2B = adherent clot; 2C = flat pigmented spot; 3 = clean based ulcer; 1 through 2A all get endo Tx and IV PPI x72h; 2B consider endo tx and GIVE IV PPI x72h; 2C and 3 can be DC home on PO PPI without 72 h
Most likely dx for older ppl with painless large volume hematochezia? Dx test if HD stable? Dx test if unstable?
Diverticular Bleed; prep and colonoscopy; angiography
A patient who is septic and on pressors with rising lactate and CT scan showing jejunal edema likely has _______
Mesenteric Ischemia; of note, the lactate will rise more and more with progressively more transmural inflammation
What are some options for patients who have had a GIB d/t NSAIDs who must remain on NSAIDs?
Can switch to celecoxib or continue NSAID at lowest possible dose and add PPI
What are some adverse effects of supratherapeutic tacrolimus levels?
Tremors, HTN, and HA
What are two major things that should be considered and ruled out in a pt with acute pancolitis in IBD pt that is worsening despite high dose IV steroids?
C. diff should be checked and ruled out; CMV colitis should evaluate with flex sig and biopsy (from center of ulcer, usually periphery); CMV classically gets worse with increasing immunosuppression and can Tx with IV ganciclovir
What are the 3 major types of Hypereosinophilic Syndromes and why do they occur?
1 ) Idiopathic 2) Myeloproliferative Disorder HES assoc with FIP1L1-PDGFRA or 3) Lymphoproliferative disorder that secrete lots of IL-4/5
When should a liver biopsy be done in the inactive carrier state for HBV?
If trending the LFTs and viral load show either elevated LFT or viral load >2000 (2 times, 2 months apart) the biopsy will prove HBV related inflammation; if inflammation or fibrosis is present then tx (Also can use elastography to look for fibrosis)
What can be considered as a dx in patient with sx similar to mesenteric ischemia who had a recent intra-abdominal infection?
Mesenteric Venous Thrombosis due to the inflammation leading to hypercoagulability
How would you manage a pt with mild diverticulitis without concerning radiographic features who is otherwise healthy and immunocompetent?
Can be DC home on PO Cipro and Metro
A patient with recent cardiac surgery and worsening ascites and elevated JVP should be evaluated for? What is the expected SAAG and total protein in fluid?
Constrictive pericarditis (primary liver usually not have elevated JVP); SAAG >1.1 with total protein >2.5 suggesting cardiac ascites
When is percutaneous drainage of a pericolic abscess complicating diverticulitis needed?
If abscess is > 3cm
Patients with Crohn disease can develop vesiculobullous and erythematous rashes with taste abnormalities known as ______________ due to deficiency of _____
Acrodermatitis Enteropathica-like syndrome due to Zinc deficiency
What is the best initial mgmt of a Shatzki ring?
Balloon or Savory Dilation; these occur at the GE jxn and often cause dysphagia with meat and bread
What is the most likely reason for recurrent food impaction in a nonelderly man with hx of allergies?
Eosinophilic Esophagitis–occurs because the inflammatory response leads to rings/strictures in the esophagus called Trachealization fo the esophagus
Is HCC a contraindication to liver transplant?
No. If the patients meet the MILAN CRITERIA they can still get transplant; Up to 3 HCC lesions <3 cm or 1 lesion <5 cm and they get MELD exception points; recall HCC dx mainly requires CT or MRI evidence of intense arterial enhancement with venous washout
How does the liver profile of a pt with HSV hepatitis look? Tx?
Seen often in immunocompromised pts and AST and ALT in thousands but with relatively normal bilirubin (another one that can do that is acute Wilson’s though maybe not 1000s)
In what two scenarios is ambulatory pH monitoring the most useful?
1) To assess how well a PPI is working in patients with GERD who persist despite PPI tx 2) to confirm the diagnosis in a patient who does not have evidence of mucosal injury on EGD
What is the best next step in diagnostic mgmt for a pt with newly diagnosed Crohn’s disease involving the TI and ascending colon?
MRE of the small bowel to look for extent of dz and to identify things like stricture or fistula
What is the tx for Type 1 Gastric NETs?
Endoscopic removal if the lesion is <1 cm or if <5 are present; no need for CT abdomen bc rarely metastatic; often develop in Atrophic Gastritis so gastrin is high but that is bc of lack of parietal cells to make HCl and NOT because there is a gastrinoma present
What is the best imaging study for a patient with painless jaundice and weight loss with a normal CT scan of the pancreas
MRCP as small pancreatic masses <3cm can be missed; recall that RUQ US does not visualize the distal duct well
In a patient with suspected UGIB and high Glasgow-Blatchford score how soon should EGD be done if nonvariceal? If suspected variceal?
Within 24 hours; much sooner otherwise (within 8 hours)
How is FAP inherited? Aside from colon CA where else in the GI tract are more cancers found? What 3 other places can cancer occur?
AD; duodenal (i.e. periampullary); medulloblastoma, papillary thryoid CA, and hepatoblastoma
What is the criteria from Mayo Clinic called that is used to diagnose Autoimmune Pancreatitis? What is the typical finding of the pancreas? Dx test?
HISORt Criteria; recurrent pancreatitis with irregular pancreatic duct and sausage shaped pancreas; IgG4 (order IgG subtypes)
What is the best modality for detecting insulinomas?
EUS as they are often small and not well detected on CT scans
Aside from endoscopic therapy, what is the management of patients with high risk PUD ulcers?
Keep on IV PPI x72 hours (active spurting, oozing, visible vessel, or adherent clot–in descending order of severity per Forrest Classificaton)
What is a common cause, world wide of portal HTN sometimes with normal LFTs? Dx test?
Schistosomiasis (mansoni MC type); Stool O/P–Dz is called Symmers periportal fibrosis
When might you check HLA-DQ2 and HLA-DQ8 in a patient being worked up for Celiac dz?
If the serology (TTG, anti-gliadin, anti-endomysial) is negative but the pathology is consistent (lymphoplasmacytic infiltrate with villous atrophy) with the dz
When should an EGD be done in patients presenting with variceal hemorrhage? What can you say about early TIPS in patients with variceal bleeds?
Earlier than a normal GIB so like 8-12 hours latest; recall also give IVF and blood but don?t overtranfuse bc increases portal pressures; give octreotide and CTX as well; there is data suggesting early TIPS within 72h may be good but not yet standard of care
Tx of pt with biliary pain and gallbladder EF <40%
Cholecystecomy for Functional Gallbladder Disorder
What are the two big criteria to surgically resect a hepatic adenoma?
If it is >5 cm or if it exhibits B-catenin nuclear reactivity; B-catenin increases risk of transformation to HCC
Which Anti-TNFs are approved for Crohn and which fur UC?
UC = Infliximab, adalimumab, golimumab; Crohn = infliximab, adalimumab, and certolizumab
How does ischemic colitis often present?
May have a clear history of hypotension or dehydration but may just have pain then diarrhea then a day or so later some blood
What disorder can cause abnormal behavior in a young person with elevated AST:ALT 2:1 but much higher than EtOH who has a relatively normal ALP?
Wilson’s disease (low ceruloplasmin, high urinary copper)
What is the best test to discover the etiology of an elevated gastrin level in someone off of PPIs for 2 weeks?
Secretin stimulation test; Stimulates gastrin release from gastrinomas but inhibits gastrin release from normal stomach; so a positive secretin stimulation test in the setting of an elevated gastrin level basically proves that a gastrinoma is present
What is the deal with high residuals in enteral nutrition?
Generally would not hold for residuals less than 500 cc unless there are sx of intolerance; can just elevate HOB
The intestinal malignancy most associated with Celiac disease is ___________
Enteropathy Associated T Cell lymphoma
What is the mgmt of Acute Biliary Pancreatitis with sx of acute cholangitis? How is it different from acute biliary pancreatitis alone?
Antibiotics and urgent EGD within 24 hours; EGD needs to happen much quicker if cholangitis and needs abx; both need chole within 72 hours or so
The HISORt criteria are used for _______
Helping to make a diagnosis of Type I Autoimmune pancreatitis (Mayo Clinic Guidelines); Assoc with IgG4 often with irregular PD and a sausage shaped pancreas
What disease causes flask-shaped ulcers in the intestines? Tx?
Entamoeba histolytica; Metronidazole first to kill the organism then paramomycin a luminal agent to kill cysts (also if use paramomycin upfront can cause bad diarrhea)
A young man who has been treated for IBD with thiopurines or TNFs for several years who develops weight loss and night sweats and fevers may have __________-
Hepatosplenic T Cell Lymphoma
What is the ratio of spironolactone to furosemide for patients being treated for ascites, hepatic hydrothorax etc?
100:40; as kidneys and BP tolerate; also same rules for spirono apply as CHF–cutoffs are sCr >2.5 in men or 2 in women; K >5
What is the management of a solitary juvenile polyp? How is that different from juvenile polyposis syndrome?
Removal and then no worries as they confer no future health risk; Juvenile Polyposis Syndromes on the other hand (SMAD4, BMPR1A genes) require EGD and Colo q2-3 years starting at age 15
If you are going to order a PPI gtt how is the order placed?
Need to give 80 mg IV bolus once then 8 mg/hr of pantoprazole (the bolus matters and decreases mortality and rebleeding rate after endoscopic tx)
What is the first line test for oropharyngeal dysphagia?
i.e. coughing choking while eating; Videofluoroscopy also known as an MBS
What diagnosis is made in patients with chronic diarrhea who have an EGD showing predominant eosinophilic infiltration into the mucosa?
Eosinophilic enteropathy; can lead to protein losing enteropathy (Tx is systemic steroids)
What disease is a consideration in pt with IBS like sx who have urticaria pigmentosa and anaphylaxis?
Systemic Mastocytosis; will have elevated tryptase levels and evidence of infiltration of abnormal mast cells (most common place is BM); assoc with C-KIT mutation and if D816V resistant to imatinib need midostaurin or new med Avapritinib
What is the preferred mgmt for a patient with active GIB and hemodynamic instability?
Angiography especially if there was an original EGD that was negative; after that then can do a diagnostic EGD or colonoscopy depending on the source
What is the most appropriate mgmt of a drug induced liver injury that does not have coagulopathy or hepatic encephalopathy?
Watchful waiting and discontinue drug (i.e. person on augmentin gets jaundice and LFTs up) if HE or coagulopathy more serious and NAC can be useful
This disorder has microscopic inflammation but an endoscopically normal appearing colonic mucosa and does NOT have systemic sx? Associated with what other GI dz?
Microscopic Colitis (Lymphocytic = >20 lymphocytes per 100 epithelials; Collagenous >10 um band of collagen); Celiac Dz
A patient failing TNF alpha inhibitors should have this lab checked prior to advancing therapy _________ (i.e. to an anti-integrin such as vedolizumab)
Antibodies to the drug (i.e. infliximab antibodies) often ppl are tx with TNF and addition of MTX or a thiopurine to prevent antibody formation
Why does the gallbladder fill with bile?
Because when the sphincter of Oddi is closed it goes back up and into the cystic duct; a sphincterotomy would attenuate this and is useful in bile leaks
What is the most appropriate mgmt of pt with suspected Sphincter of Oddi dysfxn?
Depends: If Type 1 with BOTH dilated CBD and elevated LFTs then do sphincterotomy; If Type 2 with EITHER elevated LFT or dilated CBD then sphincter of oddi manometry and if confirmed then sphincterotomy
What is the inactive carrier state of HBV? What is the mgmt?
Postive HBsAg but negative HBeAg with + Hbe-Ab and normal LFTs with viral load <2000; periodically check LFTs and viral load
The Glasgow-Blatchford criteria are used for ______
Determining need for intervention for a UGIB
Ducts that drain directly from the liver into the gallbladder and may be responsible for post-op bile leaks are called __________
Ducts of Luschka
This rare pancreatic tumor occurs in young women and is often extremely large but has relatively low risk of malignant degeneration?
Solid Pseudopapillary Neoplasm of the pancreas
What SAAG is consistent with portal HTN? How does the ascites protein help in this situation?
SAAG >1.1 (serum albumin minus ascites); if total protein >2.5 suggests cardiac ascites but if less than 2.5 suggests liver as primary issue
Which patients without alarm sx should NOT be treated with a trial of PPIs for GERD?
Patients from areas with high endemic rates of H. pylori; i.e. Brazil
What should you do for a pt who is HD unstable with active GIB who has had a negative EGD and colonoscopy?
Angiography
How can you manage a pt with a partial response to GERD sx with a daily PPI?
Make sure taking 30 min prior to meal; then can safely go up to BID (assuming young and no alarm sx); if still bad then need EGD (if no lesions there and bad can do ambulatory pH)
What is the most appropriate first line medication for mild to moderate UC flares?
A 5-ASA (mesalamine, sulfasalazine, balsalazide); if nonresponsive then can tx with prednisone, thiopurine or anti-TNF, or anti-integrin (maybe cyclosporine but no one does)
Best dx of acalculous cholecystitis? Tx?
RUQ US; often a percutaneous cholecystostomy
What is used to treat severe alcoholic hepatitis? How do you know when? What is used to treat acetaminophen OD? What about non-acetaminophen related ALF?
Prednisolone if Maddrey >32 or if contraindication then pentoxyfylline (acts on TNF-A); NAC; NAC
What is a common presentation of microscopic colitis? What are the two types?
Multiple episodes of watery and nonbloody diarrhea per day; Lymphocytic Colitis and Collagenous Colitis
What happens to liver enzymes in TPN pts and what is the theorized reason?
They tend to rise (both transaminases and ALP) but via unclear mechanisms and it is thought to be due to development of steatosis and cholestasis
In whom might anorectal manometry be a useful test?
Patients with chronic constipation or incontinence
What diagnosis has sx very similar to PUD and often with epigastric pain and post-prandial fullness but with a negative EGD
Functional Non-Ulcer dyspepsia, can do PPI but if refractory may need low dose TCA such as nortryptiline
What is the benefit of capsule endoscopy over angiography or tagged RBC scan for small bowl bleeding? MC cause of small bowel bleeding in elderly?
Angio and nuc scans require active bleeding; capsule can look for source even if not bleeding; AVMs
How do you calculate stool osmotic gap? What is osmotic and non-osmotic diarrhea?
290 - 2(Stool Na + Stool K); Gap more than 100 is likely osmotic, between 50-100 equivocal; if <50 likely not osmotic
In general this is the MC cause of abdominal pain, cholestatic LFTs and a dilated CBD particularly in young ppl
Choledocolithiasis; if older and painless jaundice with dilated CBD and maybe Curvosier’s sign (palpable painless GB) then the dx is pancreatic head mass
How is the management of Barret with dysplasia different from Nodular Barret with dysplasia?
Normally do endoscopic ablation; if nodular need to do endoscopic mucosal resection
How does the tx of hyperferritinemia differ in patients with primary (hereditary) hemochromatosis vs. secondary hemochromatosis?
Primary gets phlebotomy to goal ferritin of 50-100) whereas secondary (already anemic) would get iron chelation with deferoxamine
Measurement of this can help differentiate inflammatory diarrhea from noninflammatory
Fecal calprotectin (a neutrophil derivative); only good for screening; would not trend in known flare like you do for CRP and ESR
What can you say about AFP and US for screening for HCC?
Pt with cirrhosis should get screened for HCC with q6-12 month US but do not need AFP (though often still done)
What is the MC cause of N/V and nonbloody diarrhea in pt s/p BMT with negative stool studies including O/P?
Acute GVHD and tx would be intensification of immunosuppression
How do you manage patients with serrated polyposis syndrome?
Depending on number of polyps can do q1 year colonoscopy but since mostly right sided can potentially do extended right hemicolectomy
Which HCV genotype has a high likelihood of sustained virologic response with sofusbuvir and ribavirin?
HCV genotype 2
Which of the following is evaluated better with a RUQ US and why? Cholecystitis vs. Choledocolithiasis
Cholecystitis as a US is not great at visualizing the distal duct due to bowel gas; if a stone is in the proximal duct, sensitivity for choledochus is high, if it is distal need MRCP
How do you manage a pt with HCV ab positivity but negative HCV RNA
No further testing, pt does NOT have HCV but cleared the infxn
A patient with chronic GIB and eosinophilia should be evaluated for ______
Strongyloides infection as they can last for years (Check Abs); recall that Strongyloides Hyperinfection Syndrome occurs when the nematodes go through bowel and cause polymicrobial bacteremia with GI bugs
Rectal hydrocortisone and sucralfate enemas is a good tx for ______
Chronic Radiation Proctitis
What is the concern with progressive solid food to liquid dysphagia? Why different than hx of always having solid and liquid dysphagia?
Progression implies cancer bc it enlarges; if always had trouble with solids and liquids likely achalasia bc the spasm is so tight not even liquid can pass
What are the biomarkers to suggest that a patient has severe C. diff?
sCr >1.5 and WBC >15k; tx is PO vancomycin 125 mg qid; fulminant should get 500 qid (and IV metro if ileus)
What should be considered in patients with diarrhea lasting greater than 7 days?
Parasitic infections w/ Giardia and cryptosporidium being the MC in the US; check O/P
What should be considered in patients with Celiac who have severe watery diarrhea but adhere to gluten free and have undetectable TTG IgA levels?
Microscopic Coliti= known association with Celiac (Lymphocytic = >20 lymphocytes per 100 epithelials; Collagenous >10 um band of collagen)
What are the options for patients with chronic pancreatitis pain who are refractory to tylenol, NSAID/Tramadol and pancreatic enzymes?
Can do pregabalin; Celiac plexus blockade is short lived and with variable results so better for cancer pts; last line is Whipple or distal pancreatectomy (which is really proximal pancreas)
What is the best mgmt for a pt on IV PPI who gets scoped and found to have clean-based ulcer with no active bleeding?
Switch to PO PPI and DC home early (Forrest Class III); this can also be done in Forrest Class 2C (flat pigmented spot)
Which of the following occurs about equally among the sexes? Which is only in women? IMPN and MCN
IPMNs are equally distributed and MCNs are almost always in women and have ovarian stroma; MCNs have higher malignant potential
What lab needs to be checked prior to starting a patient on a thiopurine (azathioprine or 6-MP for UC)?
TPMT (Thiopurine methyltransferase) as if it is low then the drug will build up and cause BM toxicity; also be careful with Xanthine oxidase inhibitors as the two enzymes that metabolize are xanthine oxidase and TPMT
What is the worst antibody to use to screen for Celiac dz? What other GI disorder is Celiac assoc with? What cancer?
Anti-gliadin antibody; microscopic colitis so consider in pt adheret to diet who has bad watery diarrhea; Enteropathy Associated T cell lymphoma
Who is the ideal candidate for celiac plexus blockade for pancreatic pain?
Cancer patients because the effects are short lived but so is their lifespan; chronic pancreatitis is not such a good idea because they will need repeat procedures which have risks
What is the best initial test to screen for celiac dz?
IgA Tissue Transglutaminase; and total IgA level; better than anti-endomysial and anti-gliadin; anti-gliadin is the worst
If a patient has compensated cirrhosis and undergoes screening EGD which does not show varices, when should they be re-screened?
In 3 years; grade 2 or greater would get BB or variceal ligation
In addition to abx (3rd generation ceph), the drug that should be added to the mgmt of SBP is _______
Albumin 1.5 mg/kg on Day 1 and 3 or 100 q8h x3 day (octreotide and midodrine used in HRS but not SBP)
Which IBD is characterized by transmural inflammation? Mucosal inflammation? What is seen on biopsy classically for the two?
Transmural = Crohns; Mucosal limited = UC; Noncaseating granulomas in Crohn’s, crypt abscess in UC
What is the best initial mgmt of hepatic hydrothorax? Dose of meds?
Salt restriction and IV diuretics with spironolactone:furosemide of 100:40 (or 2.5:1); if refractory then is a MELD exception point and needs TIPS or transplant
How should you treat acute HBV infection i.e. pt coming in with markedly elevated transaminses, negative HBS-Ab but + HBS-Ag
Observation and serial monitoring of labs, only if liver failure would you give antivirals because even with elevated transaminases, most ppl will ultimately clear the infxn (Clearance = clearance of HBsAg within 6 mos)
How should you manage a low risk gastric ulcer (i.e. Forrest Class 3 w/ clean based ulcer) who is NPO on IV ppi?
Can switch to PO PPI bid, check H. pylori, and DC soon if tolerate food; however, need to schedule repeat EGD to rule out gastric CA
What is a MIBG scan used for?
To isolate a pheochromocytoma (Metaiodobenzylgaunidine)
What is the likely dx in a pt with difficulty swallowing solids and liquids (due to feeling of getting stuck in chest) with no clear history of progression?
Achalasia because the muscle is so tight that it wont let liquid pass; if progressive think CA (Tx achalasia - botox, POEM, or Heller Myotomy)
What is first line for Colonic Pseudo-obstruction (Ogilvie)? What if not responding?
NGT and Rectal tube decompression; IV neostigmine as long as no heart block and need cardiac monitoring during
How often should 1-2 tubular adenomas removed be followed? 3-10? >10? What about a polyp > 10 mm? Any size with dysplasia or villous features?
If only 1-2 can do q5 years; 3-10 then q 3 years; if more than 10 every 1-3 years; if more than 10 mm or any dysplasia or villous features then q 3 years
How does nonulcer dyspepsia present?
Can present like PUD with pain or early satiety but EGD will be negative
What is seen on duodenal biopsies of Celiac Dz?
Intraepithelial lymphocytosis, crypt hyperplasia, and villous atrophy; Crohn’s would have a neutrophilic infiltration
What is an infectious agent, often a lung issue, but that can cause infectious diarrhea in an HIV patient?
MAC also disseminated MAC can occur with retroperitoneal LAD etc (often CD4 <50) and ppx with azithro; tx is ethambutol and clarithro
Patients with a MELD of > _______ should be evaluated for transplant; what MELD and bilirubin are contraindications to TIPS?
15; MELD >15-18 or bilirubin >4 is contraindication to TIPS
What is geographic tongue?
Benign migratory glossitis, it is benign and requires no tx
What T cell lymphomas are associated with 1) Celiac and 2) IBD?
Celiac = Enteropathy Associated T cell lymphoma; Hepatosplenic T cell lymphoma occurs in young men with IBD treated with TNFs or thiopurines for several years
True or false: Anti-TNF therapy is safe in pregnancy
True
How is an aortoenteric fistual generally diagnosed?
Visualization of dacron on EGD (only really in open repairs not so much the endovascular ones) if oozing then CTA
What is the most appropriate mgmt of Tropical Sprue?
Tetracycline 250 mg qid x 3-6 months
What should be done for patients on ASA for CV disease with a UGIB due to PUD?
Can resume in 3-5 days (N.B. this does increase re-bleed rates but overall mortality is improved)
Why do we do repeat EGDs for gastric ulcers? What about duodenal?
To rule out that it is a gastric cancer; you don?t really re-scope for duodenal
Phlebotomy is an important part of this viral-induced cirrhotic condition
Porphyrea cutanea tarda (complication of HCV cirrhosis)
Where do most interval colon cancers (i.e. between recommended screening periods) arise in the colon?
Right side and often these are sessile serrated polyps which are easily missed, they are MC on the R side
An ALT > _____ in pt with cholecystitis tends to suggest that cholangitis may be going on? Why might LFTs rise slightly in pt with cholecystitis?
200 (per Levenick); due to inflammation of the gallbladder fossa and hepatocytes
