OME GI Flashcards
1
Q
Clinical picture consistent with choledocolithiasis progressed to ascending chilangitis with sepsis
Next step
A
ERCP
Diagnostic and therapeutic
Don’t wait for RUQ US here or MRCP, this is emergent
2
Q
What bugs is amp gent and metro treating
A
amp gent - gram negatives
metro - anaerobes
3
Q
Treat CAP with abx
A
Ceftri and Azythro or Moxi or Azythro alone if not being admitted
4
Q
TF
Pip/Tazo will cover gram negatives and anaerobes in ascending cholangitis
Necessary to add vanc?
A
T
No need for vanc
5
Q
Ceftriaxone coverage
A
Gram positives
Gram negatives
Good skin penetration
A shotgun
6
Q
Painless jaundice obstructive biliary labs but normal biliary tree on RUQ US in 40yo female think
A
PBC intrahepatic obstruction
7
Q
Courvoisier’s sign
A
Palpable but non-tender gallbladder – painless distended gallbladder suggests cancer or stricture from PSC
8
Q
Patient with risk factors (female fat forty fnativeamerican) has acute cholecystitis symptoms (RUQ pain and tenderness some fever no jaundice) but RUQ US is equivocal (some mild wall thickening gallstones biliary sludge but no pericholecystic fluid)
Next step?
A
HIDA nuclear scan
can see if gallbladder fills or obstructed cystic duct
9
Q
TF
Doppler flow ultrasound can evaluate biliary flow
A
F
Biliary flow is too slow for doppler
Doppler usefulness is limited to vasculature – eg portal vein or hepatic vein thrombosis
10
Q
Large esophageal ulcerations and owl eyes (large central basophilic nuclear inclusions separated by a halo) on biopsy
Dx
Tx
A
CMV esophagitis
Valgancyclovir
11
Q
Nuclear molding with inclusion bodies on path from vesicles on an erythematous base in the esophagus
Dx
Tx
A
Herpes zoster
Acyclovir
12
Q
TF
Herpes can cause esophagitis
A
T
13
Q
Dysphagia esophagitis atopy by history eosinophils on biopsy you are thinking eosinophiliic esophagitis next step
A
6-8 weeks acid suppression with ppi because GERD can produce eosinophils and must rule out
14
Q
Treat eosinophilic esophagitis
A
6-8 weeks acid suppression with ppi because GERD can produce eosinophils and must rule out
Oral budesonide when dx confirmed with failure of 6-8 weeks ppi (or another oral steroid that you usually see in inhaled form eg fluticasone)
15
Q
TF
Gluten free improves eosinophilic esophagitis
A
F
Can be food allergy component and benefit from avoiding, but no evidence of gluten
16
Q
Presentation
Diagnosis
Treatment
Eosinophilic esophagitis
A
Dysphagia esophagitis history of atopy
Endoscopy esophagitis and Biopsy eosinophils
6-8 wk ppi trial to r/o gerd
Repeat endoscopy
Oral formulation of a typically inhaled steroid
Avoid foods that seem to cause
17
Q
large central basophilic nuclear inclusions separated by a halo on path
Aka
Dx
Tx
A
Owl eyes inclusion bodies
CMV
Valgancyclovir
18
Q
Esophageal cancer suspected
First diagnostic test
A
Barium esophagram
- first test to eval esophagus for almost anything
Will get EGD scope but barium swallow first, will help id location of mass and lymph nodes eg for EUS or other EGD diagnostic adjuncts
19
Q
Why give LR instead of NS for resuscitation of hemorrhaging pt
A
Enough NS can cause acidosis
Can compound lactic acidosis of hemorrhagic shock
20
Q
Transfuse hemorrhaging pt to Hb of __
A
Transfuse hemorrhaging pt to Hb of 7 or improvement of symptoms
21
Q
Treat significant upper gi bleed eg in ed
A
2 large bore IVs Fluid LR bolus Type and cross transfuse as needed IV PPI Call GI for EGD scope
If cirrhotic - Octreotide for varices, Ceftriaxone ppx for SBP
22
Q
Curling ulcer
Cushing ulcer
A
Curling ulcer in Burn pt
Cushing ulcer in ICU pt
Peptic ulcers…
23
Q
All the tests for h pylori
A
Urea breath test - non invasive, active h pylori
Serology - exposure to h pylori ever
Stool antigen - monitor for eradication
Biopsy - best test to confirm dx
24
Q
Triple therapy for h pylori
Quadruple therapy
A
PPI bid Clarythromycin 500mg bid Amoxicillin 1000mg bid (Metronidazole 500mg bid if penicillin allergic)
- less effective but more tolerable so more effective in the end
Bismuth Subsalicylate 525mg qid Metronidazole 250 qid Tetracycline 500 qid Ranitidine 150 bid
25
Achalasia in a younger patient may be a sign of _____ disease
Achalasia in a younger patient may be a sign of Chagas disease
26
Treat achalasia
Myotomy if good surgical candidate
Dilation if not
Meds and botox don't realky work
27
Define pseudoachalasia
Cancer causing symptoms of achalasia
28
Corkscrew appearance of esophagus on barium swallow
| Dx
Diffuse esophageal spasm
29
Circumferential esophageal stricture causing steakhouse dysphagia (to poorly cut or chewed food)
Aka
Shatzki's ring
30
Next step on first time presentstion of probable GERD
PPI.... plus lifestyle modification
But PPI if only one choice -- strongest therapeutic and diagnostic intervention... lifestyle evidence weak
31
When to get ambulatory pH monitoring for GERD
Preop
or
When PPI and lifestyle not helping, to conform symptom assoc w acid
32
GERD with emesis and dysphagia... get UGI or EGD?
EGD for GERD with alarm symptoms
UGI otherwise first for dysphagia, then EGD after but this case has alarm symptoms so straight to EGD
33
what CCBs for nutcracker diffuse esophageal spasm?
Diltiazem Verapamil
(non-cardiac)
Not nifedipine
34
describe Barret's on EGD
salmon-colored lesion with intestinal metaplasia
35
manage Barret'ts esophagus
high-dose PPI
| surveillance EGDs to eval for resolution vs progression (dysplasia, adenocarcinoma)
36
what kind of epithelium in Barrett's esophagus
___ not ___
Columnar (duodenal)
not glandular (gastric)
37
treat low grade dysplasia of esophagus
vs high grade dysplasia
low grade dysplasia -- endoscopic destruction of the lesion to prevent progression to adenocarcinoma
high grade - surgical resection, treat like adenoma
38
best test to confirm eradication of h pylori
stool antigen
39
3 patients who benefit from PPI PPX
and maybe a 4th
burn pts
icu intubated pts
high intracranial pressure pts
maybe postop pts npo for a long time
40
guess the ulcer cause:
single deep heaped up margins
single deep not heaped up
multiiple shallow
single deep heaped - cancer
single deep not heaped - h.pylori
multiple shallow - NSAIDS
multiple deep - Gastrinoma
41
before getting nuclear emptying study to diagnose gastroparesis in a vomiting diabetic, you must get...
must get an EGD first to rule out mechanical obstruction before you make swallow stuff for nuclear emptying study and diagnose gastroparesis
42
treat diabetic gastroparesis
glycemic control
small meals low in fiber
maybe metoclopramide or erythromycin for exacerbations but avoid long-term
43
bbw metoclopramide
tardive dyskinesia
44
multiple deep ulcers on EGD with elevated serum gastrin, next steps
secretin stimulation test to confirm Gastrinoma
CT vs somatostatin receptor scintography to identify location of lesion for surgery and stage
45
when to discontinue PPI and reassess gastrin level in setting of multiple deep gastric ulcers and high serum gastrin
when serum gastrin v300
(this low elevation may have been caused by compensation acid production in response to PPI
(if gastrin higher, start thinking secretin stimulation test, CT vs somatostatin scintography and surgery for gastrinoma)
46
gastrinomas (zollinger ellison syndrome) is diagnosed by
obtaining an elevated gastrin then secretin stim test then staging with CT or somatostatin scintography
47
lymphoma associated with h.pylori causing gastric outlet obstruction...
what kind of cancer?
how to treat?
MALToma
treat H.Pylori and maltoma will regress
48
camping fresh water streams and diarrhea think this bug
Giardia
49
most common cause of infectious diarrhea that is not viral -- no risk factors given, they just ask for most common organism... what is it?
Campylobacter
50
causative bug in traveler's diarrhea
ETEC
| enterotoxigenic e coli
51
diarrhea, picnic, potato salad cooked eggs mayonnaise left out... what bug what mechanism
staph aureus
| toxin, not actual infeciton
52
bug in chinese buffets and fried rice
bacillus cereus
53
bloody diarrhea, raw eggs or raw poultry, think this bug
salmonella
54
HIV / AIDS and diarrhea, think this bug
cryptosporidium
55
recent abx and diarrhea think this bug
c diff
56
recent abx and bloody diarrhea or toxic megacolon think this bug
still c diff
| can present in variety of ways -- watery, bloody, toxic megacolon
57
bloody diarrhea, hemolytic uremic syndrome think this bug
EHEC O157h7
58
treat
symptomatic but not severe c diff
refractory c diff
severe c diff
symptomatic but not severe -- PO Metronidazol
refractory -- Stool Transplant (better) or PO Fidaxomycin
severe - IV Metronidazole and PO Vancomycin
59
TF
| treat severe c.diff or c.diff that does not respond to metronidazole with IV Vancomycin
F
PO Vancomycin and IV Metronidazole for severe c diff
(iv vanc won't get to gut well but iv metronidazole will)
60
TF
| IV vanc and metronidazole do not penetrate gut
Fish
IV vanc does NOT
IV metro DOES
so for severe c diff give IV metro PO vanc (po metro for symptomatic but not severe c diff)
61
30yo F with chronic diarreha, abdominal pain, problems with weight loss, osteoporosis, anti-tissue transglutaminase and anti-endomysial antibodies... next step?
Endoscopy with Biopsy to confirm dx
-absence of microvilli
THEN Gluten Free diet, vit D and Calcium supplementation, etc
62
used to treat acute diarrhea -- particularly traveler's diarrhea
ciprofloxacin
63
suspect IBS based on chronic abdominal pain and loose stools... diagnostic workup?
rule out Celiac (ant-ttg, anti-endomysial antibodies, biopsy, etc)
colonoscopy to rule out IBD
f/u re sexual abuse (highly comorbid with IBS) if ruled out Celiac
64
in IBD __ is bloody, __ is not
UC is bloody, Crohn's is not
65
young woman with iron deficiency and osteopenia despite balanced diet and exercise and no menometorrhagia
think. ..
do. ..
think Malabsorption, most likely Celiac Sprue (lose FIC folate iron calcium vitatmins in duodenum with malabsorption)
do Endomysial ab, TTG ab, or Endoscopy with Biopsy in search of celiac diagnosis
don't just supplement iron and calcium without working up for diagnosis!
66
Ceftriaxone and Azithromycin combo used for...
CAP or GC
community acquired pna
or ghonorrhea chlamydia
67
most likely cause of brisk lower GI bleed in an old
best 2 distractors
diverticular hemorrhage (diverticulosis)
- internal hemorrhoids usually not sufficient for hematochezia and acute blood loss... not as brisk...
- colon cancer more likely iron deficiency anemia than overt hemorrhage
68
when to get colonoscopy after diverticulitis
2-6 weeks
| not actively inflammed, but not so long that potential cancer brews
69
colonoscopy recs for UC
8 years after dx and then annually if no preferred colectomy
70
equivalents to q10 screening colonoscopy
FOBTx3 annually
flex sig q5 with FOBT q3
but colonoscopy preferred for sensitivity, complete colon eval, biopsy/intervention ability
71
first instinct for iron deficiency anemia in postmenopausal female or male
colonoscopy to rule out colon cancer
72
hereditary nonpolyposis colorectal cancer
aka
family hx
screening recs
lynch syndrome
family hx of lady cancers and colon cancer
screen at age 20-25 yo or 10y prior to earliest family colorectal cancer
73
treat FAP
natural history
prophylactic colectomy
thousands of polyps by age 18
colon cancer by 40
death by 50
74
Gardner's syndrome needs ___ or ___ in the vignette
osteochondroma or osteosarcoma of the jaw... and colon cancer
75
brain tumors plus colon cancer think
Turcot syndrome
(wear a turban on your head - brain tumor)
brain tumor plus colon cancer
76
picture of little hyperpigmented macules that look like freckles on the oral mucosa, think...
Peutz-Jeghers
77
bronze diabetes and cirrhosis =
pathophys
dx
HEMOCHROMATOSIS
hyperpigmented skin, diabetes, cirrhosis
disorder of excessive iron absorption from gut... no way to excrete... builds up liver and pancreas... causing cirrhosis and diabetes
get hepatic biopsy - elevated hepatocyte iron
vs HFE gene, transferrin, ferritin
78
onion skin fibrosis on liver biopsy think
primary sclerosing cholangitis
79
```
obstructive jaundice
beads on a string MRCP
male UC
ANCA
onion skin fibrosis
```
PSC
| primary sclerosing cholangitis
80
PAS positive hepatocytes is diagnostic of
sequelae
alpha-1-antitrypsin deficiency
cirrhosis and emphysema
81
cirrhosis chorea Kayser-Fleischer rings think
pathophys
labs
biopsy?
Wilson disease
impaired Copper excretion, elevated Hepatocyte copper
serum ceruloplasmin and
urinary copper elevated
no need to biopsy -- Kayser-Fleischer rings are enough (dark copper ring at outer border of iris)
82
baloon degeneration and mallory bodies on liver biopsy think
alcoholic cirrhosis (if excess alcohol)
or NASH if alc denied denied
83
pathophys of cirrhosis and emphsema in alpha-1-antitrypsin deficiency
- mut in a-1-antitrypsin
- elastase in lung unchecked
- malformed protein accumulates in liver, granulates, inflammation, cirrhosis
84
what kind of signals do you need to go from cirrhosis to thinking viral hepatitis
needles - hep c
prostitutes or asia - hep b
and positive serologies
85
cirrhosis and COPD think
alpha-1-antitrypsin deficiency
86
40-50yo F painless jaundice, cirrhosis, normal biliary imaging think
diagnose?
PBC primary biliary cirrhosis
diagnose with Anti-Mitochondrial antibody
87
Anti-Smooth antibody cirrhosis think
autoimmune hepatitis
88
p-ANCA liver stuff think
PSC - hx UC then cirrhosis or obstructive jaundice with MRCP beads on a strig in male
89
ceruloplasmin level in Wilson's disease
decreased
| -too much copper binds it and uses it up
90
anti-Smith antibodies think
Lupus
91
```
diagnoses associated with these antibodies anti:
Smith
Mitochondrial
p-ANCA
Smooth
```
Smith - lupus
Mitochondrial - PBC
p-ANCA - PSC
Smooth - autoimmune hepatitis
92
pt with cirrhosis and multiple complications (varices, angiomas, etc) and now ascites... next step CT or Paracentesis?
why?
Paracentesis - to rule out SBP spontaneous bacterial peritonitis (SBP if ^250 polys)... even if not tender...
imaging will only confirm what you already know
93
if pt has ascites
do a paracentesis
94
treat hepatic encephalopathy
lactulose (traps ammonia in gut as ammonium)
rifaximin
zinc
95
why ciprofloxacin in setting of cirrhosis
ppx against sbp
96
why furosemide and spironolactone in setting of cirrhosis
treat ascites
97
why propanolol in setting of cirrhosis
decrease portal pressures and vericeal bleed risk
98
consider TIPS when
endoscopic banding fails to control cirrhotic variceal bleeding
99
ascites with GI bleed, what to do soon as bleed controlled
ppx against SBP with ceftriaxone
100
treat pancreatitis
treat necrotizing pancreatitis
treat pancreatitis with fevers and infection confirmed on biopsy
fluids, analgesia, bowel rest
fluids, analgesia, bowel rest
ok now with HARD evidence of infection you can start MEROPENEM vs ceftri/flagyl vs cipro
101
acute pancreatitis by symptoms and lipase, pt on fluids, analgesia, bowel rest, next step CT or RUQ US?
RUQ US - common causes of pancreatitis in us are alcohol and gallstones, so rule out gallstones
CT rarely indicated for acute pancreatitis... more for poor clinical progression to assess for necrosis or secondary symptom workup
102
why is lipase and not amylase the test of choice for pancreatitis
amylase elevated in gallbladder disease and emesis as well... less specific
103
when CT for panreatitis
not usually
for poor clinical progression to assess for necrosis or workup of secondary symptoms... or if seems like pancreatitis but lipase is normal
104
what to do for classic symptoms of pancreatitis but normal lipase?
CT abdomen
get dx before tx moving to ivmf npo analgesia ruq us etc
105
why bowel rest for pancreatitis
decrease pancreatic secretions and autodigestion
106
Cyclosporine use in IBD
UC Flares Refractory to steroids
107
treat acute crohn's flares with
steroids
108
Mesalamine use in IBD
IBD limited to rectum, where mesalamine is released
109
meds for maintanence of Crohns
mesalamine (mild)
azathioprine (mod)
rituximab (mod)
infliximab (severe)
110
UC presents with
bloody diarrhea and tenesmus
111
TF
a fistula requiring surgery makes crohns "severe"
what drug to use
T
fistula = severe
escalate to infliximab (anti-TNFa)
112
macrocytic anemia in setting of IBD hints at inflammation where
terminal ileum where B12 is absorbed
113
intrahepatic cholestasis can be caused by 3 things
sepsis, meds, cirrhosis
114
isolated elevation in D.Bili and Alk Phos in setting of sepsis or other inflammatory condition think
Biliary Cholestasis
115
painless jaundice in UC patient with high D.Bili... next step RUQ US or MRCP?
MRCP for beads on a string
ruq us for gallstones less helpful in absence of pain
116
antiviral therapies for HepC
Ribavarin plus Interferon
-genotypes 1,4
Boceprevir
-genotpyes 2,3
117
serial aminotransferases is a strategy for what hepatitis virus
chronic HepB
monitor without treating until active hepatitis arises (elevated Aminotrasferases) -- then Biopsy for fibrosis and consider Antiviral... not the go-to because hepb disease does not progress unless active and antiviral therapy is life long and risks failure
118
we can cure Hep_
we can cure HepC
Ribavarin plus Interferon
-genotypes 1,4
Boceprevir
-genotpyes 2,3
119
you can only have acute Hep_ and if you do, you are sick
HepA is acute and sick only, not chronic
120
what hepatitis serologies contraindicate blood donation
HepBeAg
HepBsAg
HepCAb (without treatment)
121
guy on cruise gets hepatitis with aminotransferases into the 1000s, think acute Hep_
acute HepA (fecal oral)
| acute hepb more sex and drugs, blood transfer
122
Hep_ is always chronic, never obliterating liver or causing AST ALT into the 1000s
HepC is always Chronic, it smoulders
Hepatocellular Carcinoma and Cirrhosis but does not destroy liver with super high ast/alt
123
Hep_ is B plus
HepD is B plus
does not work without coinfection with hep b, just makes hep b worse
124
Hep_ is for pregnant women in 3rd world countries, if you see USA rule it out
HepE is for pregnant women in third world countries
125
guy with HepC but minimal cirrhosis, how often to screen for HCC?
no need
only do HCC screening in cirrhotics, and comorbid HepC or HIV increases surveillance, also HCC screen HepB even if not cirrhotic (more oncogenic)
126
who to screen for Hepatocellular Carcinoma
and how
Cirrhotics - inc freq if comorbid HepC or HIV
HepB even without cirrhosis (more oncogenic than hepc)
Ultrasound AND AFP every 6 mos
127
24yo with depression, hand tremor with activity, involuntary jerking movements, non-tender enlarged liver with modest AST ALT elevation
diagnosis
treat
Wilson disease
genetic Hepatic Copper accumulation, leak from hepatocytes deposit in Cornea and Basal Ganglia among others
treat with chelators - D-Penicillamine, Trientine....
Zinc (interferes w copper absorption)
Transplant if fulminant hepatic failure
128
liver disease and neuropsychatric symptoms in young adult think
Wilsons disease
genetic Hepatic Copper accumulation, leak from hepatocytes deposit in Cornea and Basal Ganglia among others
treat with chelators - D-Penicillamine, Trientine....
Zinc (interferes w copper absorption)
Transplant if fulminant hepatic failure
129
3 diagnostic requirements for acute liver failure
eg differentiating ALF from acute hepatitis
ALT AST ^1000 (severe acute liver injury)
Confusion, Asterixis (signs of hepatic encephalopathy)
INR^1.5 (synthetic liver dysfunction)
130
how does lactulose or lactitol work eg to treat cirrhotic hepatic encephalopathy
lactulose lactitol metabolized by colonic bacteria into acid that converts ammonia to ammonium (Ammonia Trap) and causes bowel movements which all facilitates fecal nitrogen excretion -- titrate to 2-3 semiformed stools daily
131
altered mental status, ataxia, nystagmus in alcoholc think
Wernicke Encelphalopathy (low thiaimine)
132
weeks of lower abdominal pain, bloody diarrhea, fecal urgency, now with acute worsening fever, abdominal distension, leukocytosis, hypotension, and tachycardia
diagnosis
workup
treatment
suspect IBD now with Toxic Megacolon (may be first presentation of IBD)
Upright abdominal XRay - huge colon ^6cm diameter
bowel rest, nasogastric suction, steroids and broad spectrum antibiotic (if IBD) or metronidazole (if C.Diff)
133
diarrhea cramps foul-smelling stool bloating, recent travel to developing country, benign abdominal exam
think
what if chronic
diagnose
treat
giardiasis
if chronic - malabsorption, weight loss, persistent gi distress
Stool Antigen Assay (immunofluorescence or ELISA)
alternatively stool microscopy for oocysts and trophozoites
Metronidazole
134
traveler with diarrhea treated with ciprofloxacin is being treated for...
E.Coli (most common) travelers diarrhea
135
patient with alcoholic liver cirrhosis by history, physical, labs, and ultrasound... further workup?
EGD for Esophageal Varices
| major cause of morbidity and mortality in cirrhotics
136
alcoholic cirrhotic with esophageal varices on EGD
treat
Endoscopic Variceal Ligation (preferred if large)
OR
Nadolol or Propanolol - beta blockade allows alpha constriction of mesenteric arterioles and decreased portal flow
137
TF
| an alcoholic cirrhotic with varices on EGD is a transplant candidate
F
not without Variceal Bleeding or Encephalopathy or some other sign of decompensation.... and alcohol abstinence for 6 mos
138
treat ascites due to cirrhosis
Furosemide and Spironolactone 1st line
Therapeutic Paracentesis if respiratory compromise or abdominal discomfort
