UW 1 Flashcards
1
Q
Evaluation of dysphagia
A
History of diffic initiating swallowing with cough, chocking or nasal regurg?
YES –> likely oropharyngeal –> Videofluor modiefied barium swallow
NO –> Likely esoph dysphag:
- solid + liquids –> Motility disorder –> Barium swallow followed by pssible manometry
- solid progressing to liquids –> if history of prior radiatio, caustic injury, complex stricure, surgery then barium swallow followed by possible endoscopy, if no: upper endoscopy
2
Q
oropharyngeal dysphagia
A
difficulty initiating swallowing de to inabiity to properly transfer food from mount to pharynx (due to stroke, dementia, maligancy, neuromuscular disorders etc)
3
Q
pseudoachalasia
A
due to narrowing of the distal esophagus 2ry to causes other than denervation (eg. cancer) –> can mimic achalasia
- cluses: significant weight loss, rapid onset of symptoms, older than 60
- endoscopy
4
Q
endoscopy (+) esophag ca –> next step
A
CT for staging
5
Q
if endoscopy nonrevealing and there is still concern for esoph ca
A
CT
6
Q
HCV chronic infection - manifestation
A
elevated liver functio n test, mild hepatomegaly, increased liver echogenicity, (+) HCV antibodies)), elevated HCV RNA
7
Q
HCV management - generaly
A
antivaral agents (sofosbuvir-valpatasvir) - prevent liver damage: avoid alcool, HAV, + HBV vaccination
8
Q
treatment for HIV and chronic HBV co-infection
A
lamivudine
9
Q
severe alcoholic hepatitis treatment
A
prednisolone
10
Q
diarrhea in celiac disease vs lactose def
A
celiac –> foul-smelling and greasy
lactose –> water
11
Q
factors that increase the risk for complications in diverticulosis
A
- heavy meat consumption
- aspirirn or NSAID use
- obesity
- smoking
- alcohol is associated with the formation but no with the complications
12
Q
alcohol - diverticula
A
associated in the formation
not associated with complications
13
Q
caffeine - diverticula
A
no association
14
Q
Wilson - pathogenesis
A
AR mutation of ATP7B –> hepatic copper accumulation –> leak from damaged hepatocytes –> deposits in tissues (eg. basal ganglia, cornea)
15
Q
wilson disease - clinical findings
A
- hepatic (acute liver failure, chronic hepatitis, corrhosis)
- neurologic (parkinsonism, gait disturbance, dysarthria)
- psychiatic (depression, personality changes, psychosis)
16
Q
Wilson - diagnosis
A
- low ceruloplasmin
- increased urinary cpper
- Kayser Fleisher rings
- Increased copper content on liver biopsy
17
Q
Wilosn treatment
A
chelators (eg. D. penicillamine, trientine)
zing: interferes with copper abortion
18
Q
GI bleeding causes increased BUN/cr ratio - mechanism
A
- urea production (from intestinal breakdown of Hb)
2. increased urea reabsorption (hypovolemia)
19
Q
staging of gastric adenocarcinoma - steps
A
initial endoscopy/biopsy (+_
- -> CT of the abdomen –> PET/CT, endoscopic U/S laparoscopy, CT chest +/- paracentesis/peritoneal lavage)
- limited stage –> surgical resenction
2. advancedchemo +/- palliative surgery
20
Q
the most appropriate diagnostic tests for acute HBV infection
A
HBsAg and anti-HBc : both elevatd intiial infection and anti HBc remain (+) during window
21
Q
cocaine causes gastritis - mechanism
A
vasoconstriction –> reducing gastric blood flow
22
Q
another RF for Mallory Weiss tear
A
hiatal hernia
23
Q
Mallory Weiss treatment
A
- spontaneously
- endoscopic therapy if persistent bleeding (electrocoagulation or locan injection of epinephrine)
24
Q
clue that suggests biliary pancreatitis
A
ALP more than 150
25
illicit drug that can cause acute pancreatitis
cannabis
26
nonalcoholic fatty liver disease - definition
hepatic steatosis on imaging or biopsy
2. exclusion of significant alcohol use
3. exclusion of other causes of fatty liver
27
nonalcoholic fatty liver disease - U/S
hyperechoic tecture on U/S
28
nonalcoholic fatty liver disease - treatment
- diet + exercise - consider bariatric surgery if BMI 35 or greater
29
Crohn disease - extrainestinal findings
musculoskeletal (arthritis), eye (uveitis, scleritis, episcleritis), skin (erythema nodosum, puoderam gangrenosum)
30
Crohn - diagnosis
1. elevated WBC, iron def anemia, elevated inlf markers
2. endoscopy: focal ulcerations adjacent to normal mucosa (cobblestoning) skin areas of disease
3. radiography: strictures, bowel wall thickening
31
Crohn - treatment
5-ASA drugs, corticosteroids, antibiotics
2. azathioprine
3. Anti-TNF
32
suspected gastrinoma -->
endoscopy shows multiple stomach ulcers + thickened gastric folds --> check gastrin levels off PPI threapy for 1 week
1. less than 110 --> no gastrinoma
2. more than 1000 --> check gastric ph: more than 4 it is no gastrinoma, 4 or less to further test to localize it
3. 100-1000 --> secretin stimulation test
33
hepatic encephalopahty - diuretics
low intravascular volume with:
hypokelamia --> exacerbate HE
2. metab alkalosis --> exacerbate HE
34
protein restriction to avoid hepatic encephalopaty
no because chirrotic patients need protein
| - only if TIPS
35
manifestation of high estrogen in chirrosis
1. testicular atrophy
2. gynecomastia
3. decreased body hair
4. spider angiomas
5. plamar erythema
36
1st step in evaluating asymptomatic elevation of aminotransferases
take a thorough history to rule out the more common hepattis RFs (eg. alcohol, drugs, travels, bood transfusion, sex, etc) --> life modification --> repeat --> if still high --> tests
37
Hamman sign
crushing sounds on chest ausculation (esophageal perforation)
38
esophageal perforation - diagnosis
1. CXR or CT scan: wide mediastinum, pneumomediastinum, pneumothorax, air around paraspinal muscles, pleural effusion (late)
2 .CT: esophageal wall thickening, mediastinal air fluid level
3. water soluble contrast esophagogram: leak at perforation site
39
esophageal perforation - management
1. antibiotcs + supportive care for all patients
| 2. surgical repair for significant leakage with systemic infl response
40
H. pylory - vagotomy
only if refractory
41
boerhaave syndrome - treatment
for thoracic perforation: surgery
| for cervical perforations: conservative measures (eg. antibiotics)
42
pleural fluid in Boerhaave syndrome)
exudatitve with low pH and ver high amyase (more than 2500), may contain food particles
USUALLY LEFT
43
empiric treatment for travelers diarrhea (E. coli)
short term of fluoroquinolone
44
it establish the diagnosis of diffuse esophageal spasm / treatment / pattern on esophagram
manometry
- CCBs
- crockscrew
45
common drugs associated with acute pancreatitis
1. diuretics
2. anti-seizures (eg. valproic)
3. antibiotics
(eg. metronidazole, tetracycline)
4. drugs for IBD (sulfasalazine, 5-ASA)
5. HIV related (didanosine, pentamidine)
usually mild and resolves with supportive care
46
management of gallstones
1. no symptoms: no treatment
2. biliary colic symptoms: elective laparoscopic cholecystectomy, possible ursodeoxycholic acid in poor surgical candidates
3. complicated (acute cholecystitis, choledocholithiasis, gallstone pancreatitis: cholecystectomy within 72 hours
47
postcholecystecomy syndrome
persistent abd pain or dyspepsia either postoperatively (early) or months to years (late) after cholecystecomy.
etiologies: biliary (retain bile duct, cystic stone) or extrabiliary (pancreatitis, PUD) causes
- abd imaging (U/S) followed by direct visualzation can establish the diagnosis and guide therapy
48
mechanism of malabsorption in Zollinger Ellison
pancreatic enzyme inactivation by increased production of stomache acid
49
isonizid on liver
idiosyncratic liver injury with histological features similar to those seen in patients with viral hepatitis
50
suspected galstone induced pancreatitis - test
U/S --> if not diagnostic --> ERCP
51
CT to diagnose pancreatitis
NOT required if typical symptom
52
drug that can cause pelagra
isoniazid --> B6 def --> niacin (B3) def
53
Zenker diverticulim - clinical features
- older than 60, males
- dysphagia, halitosis
- regurgiation + aspiration
- variable neck mass
54
Zenker diagnosis
1. Barium esophagram
| 2. esophag manometry
55
Zenker - management
1. open/endoscopic surgery
| 2. cricopharyngeal myotomy
56
acalculous cholecystitis
in critically ill patients
similar presentation
image: wall thickening and distention + pericholecystic fluid
- antibiotcs + percutaneous chocystostomy, followed by cholecystectomy when medical condition stabilize
57
how to confirm primary biliary cirrhosis
anti-mit
58
autoimmune hepatitis - antibodies / TREATMENT
1. anti-SMC 2. ANA
| - oral glucocorticoids
59
prencicious anemia - cancer
increased risk for gastric adenoca and gastric carcinoids
60
gastric Maltoma - management
test for H. pylori
- if (+) and low grade MALTOMA - only treat the pylori
- if (-) or high grade maltoma --> radiation, immunotherapy or single agent chemo
61
total parentarl nutrition mechanism of stone formation
no CCK secretion
62
ascites fluid characteristic - color
bloody: trauma, malignancy, TB (rarely)
milky: chylous, PANCREATIC
turbid: infection
straw: benign
63
ascites fluid characteristic - neutrophils
less than 250: no peritonitis
| more than 250: peritonitis (2ry or spontaneous bacterial)
64
ascites fluid characteristic - ascites albumin
- more than 2/5 (high protein ascites): CHF, constrictive pericarditis, peritoneal carcinomatosis, TB, Budd- Chiari syndrome, fungal)
- less than 2.5: Chirrosis, nephrotic syndrome
65
ascites fluid characteristic - serum-ascites albumin gradient
- 1.1 or more: portal hypertension
| - less than 1.1: no portal hypertension
66
hepatopulmonary syndrome
intrapulmonary vascular dilations in the setting of chronic liver disease --: platypnea (dyspnea while upright) or orthodeoxia (oxygen desaturation while upright)
67
1ry sclerosing cholangitis is associated with
1. intrahepatic or extraphepatic strictures
2. cholangitis + cholelithiasis
3. cholangiocarcinoma
4. cholestasis (low fat soluble vitamins, osteopororsis)
5. colon cancer
68
abdominal succussion splash?
place the stethoscope over the upper abdomen and rocking the patient back and forth at the hips --> retained gastric material more than 3 h after a meal will generate a splash sound --> indicating the presence of a hollow viscous filled with fluid and gas
- modest sensitivity + specificity for diagnosing gastric outlet obstruction
69
Major RF for pancreatic Ca
1. hereditary: 1st defree relatice
2. hereditary pancreatitis
3. Germline mutation (eg. BRCA, Peutz)
4. smoking (Most significant)
5. obesity
6. low physical activity
7. Nonhereditary chronic pancreatitis
70
how to confirm diagnosis of carcinoid syndrome
elevated 24h urinary5-hydroxyindoleacetic acid
71
polyps that carry the greatest risk for malignant transformation
- large (more than 1 cm)
- high grade dysplacia
- villous features
- high number (3 or more)
- sessile (nonpedunculated)
72
Spontaneous Bacterial peritonitis - clinical presentation
1. Q more than 37.7
2 abdominal tenderness
3. Altered mental status
4. hypotension, ypothermia, paralytic ileus with severe infection
73
Spontaneous bacterial peritonitis - diagnosis
1. paracentesis:
More than 250 PMNs
2. (+) culture, ofter gram (-) (E. coli, Klebsiella)
3. Less than 1g/dL protein
4. serum ascites albumin gradient less than 1.1
74
spontaneous bacterial peritonitis - treatment
- 3rd gen cephalosporin
| - fluoroquinolone for prophylaxis
75
initial episode of Difficile - treatment
Vanco PO or fidaxomicin
76
reccurence episode of Difficile - treatment
- 1st reccurence: vanco PO in a prolonged pulse taper course oOR fidaxomicin if vanco was used in initial
- miultiple recurnce: PO vanco followed by rifamixin OR fecal microbiota transplant)
77
Fulminant Difficile - treatment
- metronidazole IV + high dose PO vanco (per recum if ileus)
| - surgical evaluation
78
1ry biliary cirrhosis - drug of choice
ursodeoxycholic acid
79
elevated ALP - management
Check gGT:
A. normal: bone origin
B. high: biliary origin --> RUQ U/S + antimitochondrial:
- Dialated bile: ERCP
- antim (+) or abnormal hepatic parenchyma --> liver biopsy
- both normal --> consider liver biopsy, ERCP, observation
80
Red flags of GI bleeding
1. change in bowel habits
2. abd pain
3. weight loss
4. Iron def anemia
5. family history of colon cancer
81
minimal bright red blood per rectum - management
1. more than 50 or red flags --> colonoscopy
2. 40-49 without flags --> sigmoidiscopy or colonoscopy
3. younger than 40 without flags --> asnoscopy:
- hemorrhoids --> no further
- no source --> sigmoidoscopy or colonoscopy
82
AIDS enteropathy - mechanism
impaired intestinal surface epitihelium --> steatorrhea
83
intestinal bacterial overgrowth syndrome
abd pain/bloating and symptoms of malabsoprtion
- associated with anatomical abnormalities (eg. surgical blind loo) or motility disorders (eg. scleroderm)
- RIFAMIXIN
84
PPI increases the risk of C. dificcile - mechanism
acid suppression
| other RF is age older than 65
85
1ry biliary cirrhosis - complications
1. malabsorption, fat soluble vit def
2. metabolic bone disease (osteoporosis, osteomalacia)
3. HCC
86
toxic megacolon
total or segmental nonobstructive colonic dilation, severe bloody diarrhea, and systemic findings (eg. tachycardia)
- causes: UC (within 3 years of diagnosis), ischemic colitis, volculus, diverticulitis, infections (Difficile), obsrtuctive colon cnacer (less common)
87
Toxic megacolon - diagnosis is confirmed by
plain abd x-rays + 3 or more of the following
| 1. fever 2. pulse more than 120 3. WBC more than 10.5 4. anemia
88
toxic megacolon treatment
- meical emergency
- IV fluids, antibiotcs, bowel rest
- IV steroids for IBD
- emergency surgery if refractory
89
esophageal web - MC location
upper esophagus
90
achalasia - diagnosis
manometry: key of diagnosis --> elevated LES resting pressure, incomplete LES relaxation, decreased peristalsis of distal esophagus
- Barium esophagram: bird beak
91
achalasia - management
1. upper endoscopy to exclude malignancy
2. lapar myotomy or balloon dilation
3. botulinum toxin injection, nitrates + CCBs
92
cholestatic pattern - immediate next step
U/S (NOT ERCP)
93
Suspected esophageal variceal hemorrhage --> ...
place 2 large-bore IV catheters --> give fluids, octreotide, antibiotics --> Urgent endoscopic therapy:
A. No further bleeding --> 2ry prophylaxis: β-blockers, endoscopic ligation 1-2 wks later
B. continued bleeding --> balloon tamponade --> TIPS or shunt surgery
C. early rebleeding --> repeat endoscopic therapy --> reccurent hemor --> TIPS or shunt surgery
94
when to do endoscopy in dyspepsia
if red flags or older than 55
95
dyspepsia in younger than 55 and no red flags -->
evaluation of H. pylori (urea breath testing, stool antigen testing) can be performed --> fail to improve --> endoscopy
96
preferred test to diagnose chronic mesenteric ischemia
CT angiography
97
chronic mesenteric ischemia - treatment
1. risk reduction (eg. smoking) and nutritional support
| 2. endovascular or open surgical revascularization
98
Spontaneous Bacterial peritonitis - proteins level
less than 1
