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MTB STEP 2 (R) > MTB 2 CK - Gastroenterology > Flashcards

MTB 2 CK - Gastroenterology Flashcards

1
Q

What’s the presentation of GERD ? 5 ( Yeah you keep getting this wrong motherfu*ka )

A
  • Substernal Chest Pain without cardiac disease
  • Chronic Cough
  • Belching
  • Metallic or Sour Taste
  • Wheezing Without Reactive airway disease
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2
Q

What is a uncommon cause of GERD ?

A
  • Hyper-Ca2
  • Calcium is a Secondary Messenger for Gastrin
  • Ca increased acid production
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3
Q

Which meds are risk factors GERD ? 5

A
  • Theophylline
  • Diazepam
  • Prochlorperazine
  • Promethazine
  • Estrogen Replacement
    All relax the LES
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4
Q

What’s the best initial test ? Most accurate test ? When is endoscopy indicated ? for GERD ?

A
  • Best initial Test / tx = PPI for 4-6 weeks
  • Most accurate Tx = 24 hour pH monitoring
  • Endoscopy indicated when Sx persists or Alarm Sx :
    Dysphagia
    Odynophagia
    GI bleeding or Anemia
    Weight Loss
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5
Q

What are the Alarm Sx for GERD ?

A 
- Needs immediate Endoscopic Eval 
Dysphagia 
Odynophagia 
GI Bleeding or Anemia 
Weight loss
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6
Q

When is 24 hour pH is indicated for GERD ?

A
  • Asthma begins in a adult with GERD
  • Hoarseness
  • Sleep Apnea is comorbid
  • Med Tx has failed
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7
Q

What’s the Tx for Gerd ?

A
  • Lifestyle Change
  • Medical Tx - PPI
  • Surgical Tx - Nissen Fundoplication when PPI fail
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8
Q

What are the FYI’s of GERD ?

A
  • H. Pylori Doesn’t cause GERD
  • Carafate is always the wrong answer
  • Antacids have only 20% short term relief
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9
Q

What are the findings of schatzki ring ?

A
  • Intermittent dysphagia

- Midesophagel narrowing on barium swallowing

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10
Q

What is contraindicated in a pt with Zenker Diverticulum ?

A
  • NG tube

- Risks perforation

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11
Q

45 y.o. presents to the ED severe crushing chest pain. Troponin is normal. Ekg is normal. Fat b*tch just hit the startbucks drive thru for a cold frap. Pain doesn’t get worse with exertion. Can’t swallow and is drooling . What’s the Dx ? what’s the best test ? most accurate test ? tx ?

A
  • Esophageal Spasm
  • Best test - Barium
  • Most Accurate test - Manometry shows abnormal only at time of spasm difficult to time
  • Tx - CCB
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12
Q

Odynophagia vs Dysphagia ?

A
  • Odynophagia = usually infectious needs a biopsy
  • Dysphagia =
    younger pt = motility problem
    older pt = cancer / stroke
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13
Q

How can you tell Candidal Esophagitis vs CMV or HSV ?

A
  • Candidal can have normal esophagus without ULCERS
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14
Q

Which medications have Pill Esophagitis Reactions ?

A

1) Alendronate
2) Doxy
3) NSAIDS
4) Potassium

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15
Q

72 y.o. Pt has severe substernal chest pain. Burning in nature. Intermittent for several weeks. Sometimes worse with food. PmHx of Osteoperosis. She is Diaphoretic , Distressed . No Crepitus around the clavicles . Had a Hematemesis before admission . What’s the Dx ? most accurate test ?

A
  • Pill Esophagitis

- Most accurate test = Endoscopy

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16
Q

Eosinophilic Esophagitis Seen with what sx ?

A
  • Young Pt with odynophagia
  • Asthmatics
  • Furrowed appearing esophagus
  • Concentric grooves
    Tx Steroids
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17
Q

HSV , CMV Esophagitis viral culture must be taken at the margin. Otherwise you may get a false negative .

A
  • just FYI
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18
Q

What is the tx for Barrett’s esophagus ?

A

Depends on the Endoscopic Findings

  • Non Dysplastic or Barrett Esophagus = PPI repeat endoscopy in 3 yrs
  • Low Grade Dysplasia: Give PPIs and repeat EGD in 3-6 ( 6-12 months ? ) months
  • High Grade Dysplasia or Carcinoma : Surgery
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19
Q

Mallory Weiss vs Boerhaave’s Syndrome ?

A

MW =

  • Chest Pain
  • Hematemesis no SUB-Q Air
  • no Neck Pain tear’s usually Distal LES

Boerhaave’s =

  • full thickness tear 2/2 to retching
  • SUB-Q Air
  • Neck Pain
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20
Q

How does Esophageal Perforation present ? 4

A
  • Severe Retrosternal Chest pain after vomiting
  • Odynophagia and Hematemesis
  • SUB-Q Air
  • Radiation of pain to left shoulder
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21
Q

What is the most accurate test for Esophageal Perf? tx ?

A
  • most accurate = gastrografin esophogram
    shows contrast outside the lumen of the esophagus
  • Surgery of Esophagus and Debridement of the Mediastinum
  • Esophageal Stents
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22
Q

What are the warning signs for PUD / Gastric Ulcer ?

A

Weight loss
Early Satiety
Anemia

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23
Q

What is the Dx testing for PUD/Gastric ulcer ?

A
  • Upper Endoscopy with Biopsy to rule out cancer

- Duodenal ulcer don’t get cancer

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24
Q

How do you dx H. Pylori ? -

A
  • If Endoscopy and Biopsy are done no test needed for
    H. Pylori
  • If not then :
    1. Serology : Very Sensitive but can’t tell old vs new infections
  1. Breath Test and Stool Antigen: Useful to see if tx worked. Sensitivity of both is affected with PPI and antibiotics.
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25
Q

What’s the best test for CURED H. Pylori infection ?

A
  • Urea Breath Test
    or
  • STool sample
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26
Q

After PUD is resolved . Pt must be RE-Scoped . why ?

A
  • the only way to exclude cancer 100%

- even if biopsy is normal

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27
Q

What’s the greatest risk factor for developing Duodenal Ulcer Disease ?

A
  • H. pylori
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28
Q

What is a important agent that doesn’t not cause GERD ?

A
  • H. pylori
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29
Q

When is a 24 hour pH monitoring indicated in pts with GERD sx ? 4

A
  • Asthma begins with GERD Sx
  • Hoarseness persists
  • Sleep Apnea is comorbid
  • Medical Tx has Failed
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30
Q

What’s the best initial test for GERD ?

A
  • PPI administration
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31
Q

What are the best tx for Achalasia ?

A
  • Pneumatic Dilation
    OR
  • Surgical Myotomy
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32
Q

What’s the clinical sx for Schatzki ring ? tx

A
  • Intermittent dysphagia
  • Mid Esophageal narrowing on barium swallow
  • Pneumatic Dilation ( same tx in Achalasia ) 4% risk of Perforation
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33
Q

What are Schatzki ring almost always 97% associated with ?

A
  • Hiatal Hernia
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34
Q

What are the esophageal spasms ?

A
  • Sx - starts when drinking cold water
  • Diffuse Esophageal Spasm = 20% more contractions on manometry
  • Hypertensive Peristalsis ( Nutcracker) = normal contraction in smooth muscle via manometry
  • Tx : CCB or Imipramine
  • Barium swallow shows Rosebead or Corkscrew shape for Nutcracker
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35
Q

Odynophagia in a old vs young pt etiology ?

A
  • Old = Stroke or Cancer

- young = infectious

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36
Q

What’s the MCC of Infective Esophagitis in a AIDs/HIV pt w/

A
  • Candidiasis 90% of the time
  • Start with Oral Fluconazole
  • Then IV Amphotericin
  • Nystatin Oral = Treats only ORAL Candidiasis not Esophageal Candidiasis
  • Candida doesn’t need to be present to have pt infected vs CMV or HSV causing infective esophagitis
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37
Q

What are the causes of dysphagia ?

A
  • Achalasia
  • Esophageal Cancer
  • Peptic Rings from acid exposure
  • Zeneker
  • Esophageal Spasm
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38
Q

What are the caused of Esophagitis ?

A
  • CMV , HSV , Candidiasis
  • Pill Esophagitis
  • Eosinophilic Esophagitis
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39
Q

What’s the Tx for Plummer Vinson Syndrome ?

A

Treat Iron Deficiency first = sometimes resolves sx

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40
Q

What esophageal dx needs manometry ?

A
  • Achalasia
  • Spasm
  • Scleroderma
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41
Q

What is the only way to truly understand the etiology of epigastric pain from ulcer diseases ?

A
  • Endoscopy w/ possible biopsy
42
Q

When is Endoscopy Indicated for GERD ? -

A
  • Signs of Obstruction like dysphagia or odynophagia
  • Weight loss
  • Anemia or Heme Positive Stools
  • > 5 years of Sx to exclude Barrett’s
43
Q

What are the Sx of Esophageal Perforation ? what’s the Dx Test ?

A
  • Retrosternal Chest Pain
  • Odynophagia
  • SUB-Q air especially with Heart Beat = Hamman’s Sign
  • Radiation of pain to left shoulder

Dx
- gastrografin esophogram = shows contrast outside the lumen

44
Q

what’s the common presentation of Gastritis ? DX ?

A
  • Bleeding without Pain
  • but Severe Erosive gastritis can have pain
  • you can’t usually answer the Dx question from H/P alone

Dx = needs a endoscopy to diagnose

45
Q

Which Dx need endoscopy ?

A
  • Barrett’s
  • Cancer
  • PUD - Peptic Ulcer ( duodenal and gastric ulcer disease)
  • Gastritis ( No Ulcer )
  • Non-Ulcer Dyspepsia
  • H.Pylori - not needed but most accurate way to diagnose
46
Q

Stress ulcer prophylaxis is indicated in which pts?

A
  • Mechanical ventilation
  • Burns
  • Head Trauma
  • Coagulopathy
47
Q

PPI is the first line tx in ?

A
  • GERD
  • Scleroderma
  • PUD
48
Q

Whats the causes of Gastritis vs PUD ?

A

Gastritis

  • ETOH
  • NSAIDS
  • H. Pylori
  • Portal HTN
  • Stress - burns , trauma , sepsis , uremia

PUD - Gastric Ulcer and Duodenal Ulcer

  • MC = H. pylori
  • NSADIS = 2nd MC
49
Q

What common irritants do not cause ulcers ?

A
  • Alcohol
  • Tobacco
    they delay healing of ulcers
50
Q

What is the most accurate test for H. Pylori?

51
Q

What’s the best initial test ? Most accurate test for Zollinger Ellison ?

A
  • Endoscopy has to confirm ulcer first then ….

Best initial Test

  • Secretin challenge - pt shows high gastrin = positive
  • High Gastrin with high gastric acidity despite PPI use

Most Accurate test
- Somatostatin Receptor Scintigraphy with endoscopic Ultrasound exclude metastatic disease

52
Q

Gastrinoma is usually seen with what sx ?

A
  • Diarrhea because acidity inhibits lipase
53
Q

What’s the most common cause of UPPER vs Lower GI bleed ?

A
  • Upper GI = Ulcer Disease

- Lower GI = Diverticular Disease

54
Q

When a confirmed case of Gastrinoma is seen what’s the next step ?

A
  • Have to exclude metastatic disease
  • CT / MRI usually are done but have poor sensitivity
  • **- Use Somatostatin Scintigraphy ( Nuclear Octreotide Scan) with Endoscopic Ultrasound
  • Do this if MRI and CT are normal
55
Q

What is the cause of diabetic gastroparesis ?

A
  • autonomic damage

- unable to sense stretch of in the GI tract

56
Q

What’s the most accurate test for diabetic gastroparesis ?

A
  • Nuclear Gastric Emptying Study

-

57
Q

What sx are seen diabetic gastroparesis ?

A
  • DMII for a long time
58
Q

Normal Saline or Ringer lactate > 5% dextrose in water why ?

A
  • D5W doesn’t stay in the vascular space to raise blood pa as well as Normal Saline
59
Q

Which is the only type of GI bleed can a Physical exam determine ?

A
  • Variceal Bleeding
60
Q

What’s the MGMT goal of an GI Bleed ?

A
  • Fluid Resus First

- 80% die of inadequate fluid replacement

61
Q

56 y.o. Cirrhotic Pt has black stool . No hematemesis . NG tube shows bright red blood. What’s the Dx ?

A
  • Variceal rupture
62
Q

What is the sign for NG tube is fully sensitive ?

A
  • Bile in the Aspirate
63
Q

What’s the indication for capsule endoscopy ?

A
  • Small intestine bleeding that can’t be reached by endoscopy
64
Q

What’s the TX for GI bleeding ? 6

A

1) Fluid Resus

2) Packed RBC if HCT =

65
Q

What’s the Tx for Esophageal Varice and Gastric Varice ? 5

A

1) octreotide
2) Banding
3) TIPS = associated with portosystemic encephalopathy . Connects the hepatic vein and Portal Vein
4) Propranolol - prevent future bleeding
5) Antibiotics - prevent SBP with Ascites

66
Q

Sclerotherapy for Variceal Bleeding is NEVER RIGHT if BANDING is possible

67
Q

What’s the tx for C. Diff ?

A
  • Metronidazole

- Only Switch to PO Vancomycin if the Metronidazole didn’t work or it’s a severe case

68
Q

What’s the main diff in Sx for chronic pancreatitis vs gluten sensitive enteropathy celiac disease ?

A
  • Celiac = has Iron DEFICIENCY - needs a intact bowel to absorb Fe
  • doesn’t Need Pancreatic Juices
69
Q

What’s the best initial test? What’s most accurate diagnostic test why else do we do it ? for Celiac ?

A

Best initial test = anti- gliadin , anti transglutaminase , anti endomysial

Most Accurate = Small Bowel Biopsy to prove villous architecture abnormal and to EXCLUDE LYMPHOMA

70
Q

What’s the most accurate test? what’s the best initial test ? for Chronic Pancreatitis ?

A
  • Most accurate = NG tube Secretin Challenge - Normal response is bicarb release
  • Best initial = XR or CT for Calcifications on Pancreas
71
Q

What’s the best initial test ? what’s the tx ? for Carcinoid ?

A
  • best initial = Urinary 5 hydroxyindoleacetic acid

- tx = octreotide

72
Q

What’s the tx for IBS ?

A

Anti-Spasmodic Agents and Rest And Exercise

  • Dicyclomine
  • Hyoscyamine
73
Q

What’s the antibody seen in crohns vs ulcerative colitis ?

A
  • Chrons - Anti-saccharomyces cerevisiae pos, ANCA negative

- Ulcerative colitis - Anti-saccharomyces cerevisiae NEG, ANCA POS

74
Q

what are the extraintestinal manifestations of crohns vs UC ?

A
  • Chronic = Kidney Stones, Erythema Nodosum , Episcleritis , Aphthous Ulcers
  • UC = Pyoderma Gangrenosum , Sclerosing Cholangitis
75
Q

What’ the tx in Crohns vs UC ? acute ? chronic ?

A
  • Crohn’s - Anti-TNF-Alpha - Infliximab - Surgery is not Curative - Surgery only done for obstruction
  • UC - Cyclosporine , Infliximab , Hemi to Total Hemicolectomy - Surgery is curative
Acute = Steroids
Chronic = 5ASA-mesalamine
76
Q

WHat’s the purpose of Azathioprine and 6 mercaptopurine in IBD pts ?

A
  • Used to wean pts of Steroids - Budesonide Specific for IBD

- Give Calcium and Vitamin D

77
Q

Specific Differences between Crohn’s VS UC ?

A

Chrons -

  • Perianal Disease/Abscess ( comes from Anal crypts, don’t mix up with crypt abscess of UC that can happen elsewhere)
  • Mass and Obstructions
  • Fistulas
  • Anti-Sacchromyces Cerevisiae Pos but ANCA neg

UC

  • Cure by surgery
  • None of the above
  • ANCA pos but ASCA neg
78
Q

What’s the most accurate test for IBD ?

A
  • Endoscopy

-

79
Q

What’s the purpose of Azathioprine and 6 mercaptopurine in IBD treatment ?

A
  • Used to wean pt off of steroids

- Everyone needs Calcium and Vitamin D = prevents kidney stones

80
Q

What’s the tx for fistulae in in Crohn’s ?

A
  • Infliximab

- Unresponsive ? = Surgery

81
Q

What’s the most accurate test for Diverticulosis ?

A
  • Colonoscopy
82
Q

What can help to dec complications of diverticulosis ? 4

A
  • Bran
  • Psyllium
  • Methylcellulose
  • Inc Dietary Fiber
83
Q

Diverticulitis sx ?

A
  • LLQ tenderness ( with palpation )
  • Fever
  • Leukocytosis
  • Palpable mass sometimes
84
Q

What’s the best initial test for Diverticulitis ?

A
  • CT scan

- Don’t Colonoscopy or Barium Swallow = Will Perforate

85
Q

What are the Causes of Lower GI bleeding ? 6

A
  • AVM / Angiodysplasia = Most Common
  • Diverticular Bleed = Right Sided Most Common
  • IBD
  • Hemorrhoids
  • Ischemic Colitis
  • Cancer
86
Q

Where’s the most common Diverticular bleed vs Diverticulitis ?

A
  • DiverticulaR bleed = Right Sided Most Common

- Diverticulitis = Left Sided

87
Q

What’s the Tx for Diverticulitis ?

A
  • Cipro = Covers GM-
    AND
  • Metronidazole = Covers Anaerobes

or

Beta Lactam / Lactamase combo

88
Q

When do you operate on a pt with Diverticular Disease ? 3

A
  • No response to med
  • Recurrence is frequent
  • Perforation , Abscess , Stricture or Obstruction
  • Young Pt more often than a old pt
89
Q

Whats the MGMT of GI bleed ?

A
  • Endoscopy - therapeutic and Dx

- Technetium Bleeding scan

90
Q

What’s the dx of Spontaneous Bacterial Peritonitis ?

A
  • Infection without perforation
  • Best initial test : > 250 Neutrophils
  • Most Accurate test : Fluid Culture with no Gram Stain Findings
91
Q

What’s the Tx ? What’s the special MGMT for Spontaneous Bacterial Peritonitis ?

A
  • Tx = Cefotaxime and Ceftriaxone
  • HIGH RATE OF RECURRENCE ***
    Must prophylaxis with TMP-SMX or Norfloxacin
92
Q

When are antibiotics needed on Pancreatitis Case ?

A
  • 30% of Necrosis seen
  • Use Impenem or Mereopenem
  • only way to confirm is biopsy
93
Q

What’s the Triad for Primary Biliary Cirrhosis ?

A
  • Woman in 40-50’s
  • Fatigue and Itching
  • Normal Bilirubin with increased ALK Phos
94
Q

P. Sclerosing Cholangitis vs P. Biliary Cirrhosis ?

A
  • PSC -
    Women in 40’s 50’s
    Fatigue and Itching
    Normal Bilirubin with Inc ALK Phos
-PBC 
Pruritus 
High ALK Phos
High GGTP 
High Bilirubin
95
Q

PSC vs PBC Dx test most accurate ?

A
  • PBC = Biopsy and Anti-Mito-Ab
    vs
  • PSC = MRCP or ERCP
96
Q

P. Sclerosing Cholangitis is the only cause of Cirrhosis where you DON’T BIOPSY ***

97
Q

When is Iron Chelation Therapy indicated for Hemochromatosis ?

A
  • Can’t be managed with phlebotomy

- Are Anemic and Hemochromatosis from overtransfusion like thalassemia

98
Q

What’s the tx for Chronic HEP B vs Chronic HEP C

A
  • Hep B - can be monotherapy drug
    any vir , dine , or interferon
  • Hep C - can never be monotherapy
    Genotype 1 - ledipasvir and sofosbuvir both orally
    Genotype 2,3 - Sofosbuvir and ribavirin orally
99
Q

What’s the best initial test for Wilson’s Disease ?

A
  • Slit Lamp for Kayser Fleischer Rings

- Not ceruloplasmin - not the most accurate test b/c all proteins are down with liver dysfunction and cirrhosis

100
Q

What are the most likely Sx seen with Wilson’s Disease ? 3

A
  • Neurological Sx- Psychosis , tremor , dysarthria , ataxia or seizures
  • Coombs Neg Hemolytic Anemia
  • Renal Tubular Acidosis or Nephrolithiasis
  • Wilson’s aka Hepatolenticular Degeneration : gives Psychosis and Delusions not DELIRIUM that you would get with LIVER FAILURE
101
Q

What’s the most accurate test for Hepatolenticular Degeneration ?

A
  • Wilson’s

- Abnormally increased Copper Excretion in the urine after Penicillamine

102
Q

What’s the Tx for WIlson’s besides drugs ?

A
  • Penicillamine
  • ## Zinc - Stops Copper Absorption in the intestine

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