Internal Medicine > 11) GI (Part 1) > Flashcards

11) GI (Part 1) Flashcards

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1
Q

Zenker’s diverticulum pathology

A
  • Weakness in posterior pharyngeal wall at pharyngoesophageal junction due to loss of elasticity of UES
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2
Q

Zenker’s diverticulum symptoms

A
  • Dysphagia
  • Halitosis
  • Choking
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3
Q

Zenker’s diverticulum diagnosis

A
  • Barium esophagram
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4
Q

Zenker’s diverticulum Tx

A
  • Cricopharyngeal myotomy with or without diverticulectomy

- Surgical excision of diverticula

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5
Q

Achalasia pathology

A
  • Motor disorder

- Absence of ganglion cells of Auerbach’s plexus (Myenteric plexus)

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6
Q

Achalasia symptoms

A
  • Gradual, progressive dysphagia for solids & liquids

- Regurgitation of undigested food

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7
Q

Achalasia diagnosis

A
  • Barium Esophagram/barium swallow (“bird’s beak” distal esophagus)
  • Esophageal manometry – incomplete LES relaxation with swallowing, absence of peristalsis, Increased intraesophageal pressures
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8
Q

Achalasia Tx

A
  • Endoscopy guided botox injection
  • Pneumatic dilation
  • Surgical myotomy (modified Heller cardiomyotomy )
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9
Q

Diffuse esophageal spasm pathology

A
  • Motor disorder
  • High amplitude, repetitive, non-peristaltic esophageal contractions with intermittent normal peristaltic contractions
  • Normal function of the LES
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10
Q

Diffuse esophageal spasm symptoms

A
  • Often presents as chest pain
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11
Q

Diffuse esophageal spasm diagnosis

A
  • Corkscrew/rosary bead esophagus on barium swallow
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12
Q

Diffuse esophageal spasm Tx

A
  • Nitroglycerin SL
  • CCBs
  • Stress reduction
  • Avoid very cold or hot fluids
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13
Q

Scleroderma pathology

A
  • Motor disorder
  • Patchy smooth muscle atrophy with fibrosis, with ensuing decreased esophageal contractility and absence of resting LES tone.
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14
Q

Scleroderma symptoms

A
  • Dysphagia, odynophagia
  • Chronic reflux due to incompetent LES
  • Decreased motility
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15
Q

Scleroderma diagnosis

A
  • Stricture of the distal esophagus on barium esophogram
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16
Q

Scleroderma Tx

A
  • PPI’s
  • Promotility agents
  • Dilatation of stricture prn
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17
Q

Esophagitis

A
  • Seen in immunosuppressed pts

- Odynophagia, dysphagia, and chest pain

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18
Q

Esophagitis diagnosis

A
  • Endoscopy with biopsy

- Seen with candida, CMV, and HSV

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19
Q

Esophagitis from candida

A
  • Yellow, white patches adhere to mucosa

- Tx with PO antifungal agents (fluconazole, itraconazole)

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20
Q

Esophagitis from CMV

A
  • Large, linear ulcers (furrows)

- Tx with antiviral agents if immunosupressed (acyclovir, famciclovir, valacyclovir)

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21
Q

Esophagitis from HSV

A
  • Multiple, shallow “volcanic shaped” ulcers

- Tx with antiviral agents (valacylovir, acyclovir)

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22
Q

Causes of pill-induced esophagitis

A
  • NSAIDS
  • KCl tabs
  • Quinidine
  • Po bisphosphanates (alendronate & risedronate)
  • Iron
  • Antibiotics (doxycycline, tetracycline, minocycline, clindamycin, trimethoprim-sulfamethoxazole)
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23
Q

Pill-induced esophagitis symptoms

A
  • Dysphagia
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24
Q

Pill-induced esophagitis diagnosis

A
  • Endoscopy

- Shallow or deep ulcers

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25
Pill-induced esophagitis Tx
- Endoscopy to remove the offending medication | - PPIs to aid in healing
26
Pill-induced esophagitis prevention
- Swallow with plenty of water - Bisphosphonates: take with 4 oz of water, remain upright for at least 30 min after ingestion - NSAIDS: take after eating
27
Eosinophilic esophagitis pathology
- Strong association with food & seasonal allergies - Asthma - Atopic dermatitis
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Eosinophilic esophagitis symptoms
- Similar to GERD | - Seasonal allergy sxs (rhinorrhea, sneezing, etc)
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Eosinophilic esophagitis diagnosis
- EGD with biopsy (extensive eosinophilic infiltration with mast cells, basophils; basal cell hyperplasia)
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Eosinophilic esophagitis Tx
- Diet: avoid food allergens (cow's milk, wheat, peanut/tree nuts, eggs, soy, and seafood/shellfish*) - Medical: PPI’s, swallowed (not inhaled) steroids for 8 wks (fluticasone or budesonide), PO steroids if no improvement - Endoscopic dilation for persistent dysphagia despite Rx with dietary elimination and medical therapy
31
Mallory-Weiss Tear
- Non-penetrating (incomplete) mucosal tear at the GE junction - Prior H/O vomiting, retching - Most are self-limiting
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Mallory-Weiss Tear symptoms
- Hematemesis
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Mallory-Weiss Tear diagnosis
- EGD
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Mallory-Weiss Tx
- Fluid resuscitation, blood transfusion prn | - Endoscopic hemostatic therapy in pts with continuous active bleeding
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Esophageal Neoplasms
- Squamous cell carcinoma | - Adenocarcinoma (seen more often)
36
Squamous cell carcinoma most common causes
- Cigarette smoking | - Chronic ETOH use
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Adenocarcinoma most commonly associated with
- Barrett's Esophagus
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Esophageal neoplasms symptoms
- Progressive dysphagia | - Weight loss
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Esophageal neoplasms diagnosis
- EGD | - CT for staging
40
Esophageal neoplasms Tx
- Surgery +/- XRT, Chemotherapy - Ablation - Esophageal stent for palliation of sxs
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Barrett's esophagus pathology
- Replacement of the squamous epithelium of esophagus by columnar epithelium - Often due to severe GERD - Change in tissue has potential for esophageal adenocarcinoma
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Barrett's Esophagus diagnosis
- EGD with biopsy
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Barrett's Esophagus Tx
- Serial EGDs | - Long term PPI therapy
44
Esophageal stricture (Schatzki Ring)
- Mucosal projection that involves the most distal esophagus | - Thin, web-like constriction at/ near border of LES
45
Esophageal stricture (Schatzki Ring) pathology
- May be associated with chronic GERD
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Esophageal stricture (Schatzki Ring) symptoms
- "steakhouse syndrome" | - May present with non-progressive dysphagia for solids
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Esophageal stricture (Schatzki Ring) diagnosis
- EGD | - Barium esophogram
48
Esophageal stricture (Schatzki Ring) Tx
- Esophageal dilation | - Long term PPIs
49
Esophageal Stricture (Plummer-Vinson Syndrome) is associated with
- Iron-deficiency anemia, hypothyroidism - More frequent in women - Predominant in northern hemisphere/ Scandinavia descent - Increased incidence of esophageal SCCA
50
Esophageal Stricture (Plummer-Vinson Syndrome) symptoms
- Glossitis &/or cheilitis - Dysphagia - Reflux
51
Esophageal Stricture (Plummer-Vinson Syndrome) diagnosis
- EGD - Gastritis - Upper esophageal web
52
Esophageal Stricture (Plummer-Vinson Syndrome) Tx
- Iron replacement | - Dilation of web
53
Esophageal varices
- Develop secondary to portal HTN - Found in 50% of pts with cirrhosis - 1/3 of patients develop UGIB
54
Esophageal varices diagnosis
- EGD
55
Acute variceal bleed Tx
1) STAT resuscitation, intravascular volume support & blood transfusions 2) Abx prophylaxis 3) Vasoactive drugs (somatostatin or its analogue octreotide) 4) Banding or sclerotherapy w/ EGD
56
With uncontrolled variceal bleeding
- Balloon tube tamponade or TIPS (transvenous intrahepatic portosystemic shunts)
57
Variceal bleed prevention
- Non-selective B-blockers (propranolol) | - Variceal band ligation
58
Gastroesophageal Reflux Disease (GERD)
- Persistent reflux of stomach contents into the esophagus secondary to LES dysfunction
59
Gastroesophageal Reflux Disease (GERD) symptoms
- Heartburn - ENT complaints - Chronic cough - Dysphagia - Possible regurgitation
60
ENT complaints associated with GERD
- ENT complaints - Sour taste in mouth (water brash) - Sore throat/ Laryngitis - Hoarseness
61
GERD Tx
- Lifestyle modifications - PPIs - H2 Blockers
62
GERD long-term complicaitons
- Barrett Esophagus | - Esophageal Strictures
63
Peptic Ulcer Disease etiology
- H pylori - NSAIDs - Gastrinoma (<1%)
64
PUD diagnosis
- EGD
65
PUD Tx
- PPI therapy 6-8 wks - Eradicate H Pylori - Discontinue NSAIDs
66
Gastric ulcers
- MUST exclude malignancy via biopsy | - ALL pts with a Gastric Ulcer should have follow-up endoscopy in 6-12 wks to confirm healing
67
Complications with PUD
- GI bleeds - Perforation - Obstruction
68
H. Pylori first-line therapy
- 14 days triple therapy - Clarithromycin 500 mg BID - Amoxicillin 1 g twice daily (or metronidazole 500 mg BID) - PPI one that BID
69
H. Pylori second-line therapy
- 10-14 days quadruple therapy - PPI one tab BID - Metronidazole 500 mg TID - Tetracycline 500 mg QI - Bismuth subcitrate 120 mg QID
70
3 major types of gallstones
- Cholesterol (most common in US) - Pigment - Mixed
71
Cholelithiasis complications
- Cholecystitis - Pancreatitis - Cholangitis
72
Acute Cholecystitis symptoms
- Biliary colic - may radiate to the scapula - Murphy’s sign - Ultrasonic Murphy’s sign - 4 F’s (female, fat, fertile, forty)
73
Acute cholecystitis diagnosis
- Abdominal ultrasound most sensitive | - Hepatobiliary imaging (hepato-iminodiacetic acid/HIDA scan)
74
Acute cholecystitis Tx
- Cholecystectomy
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Choledocholithiasis may present as
- Incidental finding - Biliary colic - Obstructive jaundice - Cholangitis - Pancreatitis
76
Cholangitis usually presents as
- Fever - RUQ pain - Jaundice (Charcot's triad)
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Choledocholithiasis/Cholangitis diagnosis
- Abd ultrasound | - ERCP to visualize common bile duct stones
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Choledocholithiasis/Cholangitis Tx
- Stabilize the pt prn (NPO, IV fluids, IV abx, hydration, analgesia) - Stones should be removed surgically or via endoscope (ERCP)
79
Hepatitis A etiology
- Fecal --> oral route, contaminated food or drink sources, daycare outbreaks - No long term effects; self-limiting course
80
Hep A serology
- Positive IgM anti-HAV during or shortly after jaundice
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Hep A Tx and prevention
- Treat symptomatically | - Prevent w/ Hep A vaccine
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Hepatitis B etiology
- Transmitted via blood, semen, or bodily fluids (needles, sex, perinatal transmission) - Acute infections may fully recover or may progress to chronic Hep B
83
Sequalae of chronic Hep B infection
- Cirrhosis | - Hepatocellular carcinoma (HCC)
84
Hep B serology (HBsAg vs. Anti-HBs)
- HBsAg: (-) HBsAg = no Hep B, (+) HBsAg = positive Hep B | - Anti-HBs: (-) Anti-HBs = not immune, (+) Anti-HBs = immune
85
If the patient has Hepatitis B (Positive HBsAg) acute vs. chronic
- Acute Hep B: Positive Anti-HBc IgM, Positive Anti-HBc total - Chronic Hep B: Negative Anti-HBc IgM, Positive Anti-HBc total
86
Hep B Tx
- Monitor viral load, antiviral Rx - entecavir (Baraclude) - tenofovir (Viread) - lamivudine (Epivir) - adefovir (Hepsera) - telbivudine (Tyzeka) - Pegelated interferon – older Rx
87
Hep B prevention
- Hepatitis B vaccine
88
Common side effects of interferon
- Influenza-like symptoms | - Psychiatric side effects (depression, irritability, insomnia)
89
Contraindications to interferon
- Major uncontrolled depressive illness - Organ transplant - Autoimmune hepatitis or other autoimmune condition - Untreated thyroid disease - Pregnant or unwilling to comply with adequate contraception - Severe concurrent medical disease (severe HTN, HF, significant CAD, poorly controlled diabetes, COPD) - Age < 2 yrs
90
Hepatitis C
- IV drug use accounts > 50% of reported cases | - Little evidence for frequent sexual or perinatal transmission
91
Hep C symptoms
- Often asymptomatic | - Frequently presents in the chronic phase with borderline consistently elevated LFTs
92
Hep C serology
- Positive Anti-HCV, HCV RNA
93
Rx options for chronic HCV
- Antivirals - Ledipasvir-sofosbuvir - Simeprevir plus sofosbuvir - Ombitasvir-paritaprevir-ritonavir plus dasabuvir with ribavirin, or sofosbuvir/velpatasvir - Pegylated interferon in combination with ribavirin SQ
94
Hepatitis D
- Requires the hepatitis B virus to survive and replicate (exists as coinfection with Hepatitis B) - No specific Rx or vaccine available for Hepatitis D - Vaccinate patients for Hepatitis B
95
Cirrhosis etiology
- Alcoholic liver disease most ocmmon - Cryptogenic - NAFLD (risks: obesity, diabetes) - Hep C - Hep B
96
Miscellaneous cirrhosis etiologites
- Hemochromatosis - Wilson’s Disease - A1AT deficiency (Alpha1 antitrypsin deficiency) - Autoimmune Hepatitis - Primary Biliary Cirrhosis - Primary Sclerosing Cholangitis - Budd Chiari
97
Hemochromatosis (Bronze Diabetes) pathology
- Unrestricted absorption of iron due to inappropriately low production of the hormone Hepcidin - Excessive amounts of iron are deposited in tissues, leading to eventual organ failure
98
Hemochromatosis (Bonze Diabetes) diagnosis
- Elevated serum iron - Fasting elevated Transferrin Saturation >50% - test for iron overload - Elevated ferritin - Confirmed with genetic testing for hemochromatosis - Liver biopsy will also show excessive iron deposition
99
Hemochromatosis (Bonze Diabetes) Tx
- Avoid products containing iron (food, vitamins, etc)
100
Wilson's Disease
- More common in young men - Rare - Autosomal recessive
101
Wilson's Disease Pathology
- Low ceruloplasm (copper binding enzyme) in the serum | - Causes excessive copper accumulation in the liver and brain
102
Wilson's Disease symptoms
- Neuro-psychiatric abnormalities - Movement disorders - Psychiatric disorders - Kayser-Fleischer rings (pathognomonic)
103
Wilson's Disease diagnosis
- Low serum ceruloplasmin | - Elevated urinary copper
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Wilson's Disease Tx
- Oral Penicillamine: enhances urinary excretion of copper - Restriction of dietary copper (shellfish, organ foods, legumes) - Liver complications & cirrhosis are possible
105
Autoimmune hepatitis
- Most common in middle-aged women with co-existing autoimmune conditions
106
Autoimmune hepatitis diagnosis
- Elevated transaminases - Positive antinuclear antibody (ANA) and/or anti-smooth muscle antibody (ASMA) - Hypergammaglobulinemia
107
Autoimmune hepatitis Tx
- Corticosteroids
108
Primary biliary cirrhosis (PBC)
- Autoimmune disease | - More common in women
109
PBC pathology
- Diffuse inflammation & fibrosis involving the entire biliary tree, resulting in chronic cholestasis --> portal HTN, cirrhosis
110
PBC symptoms
- Fatigue | - Pruritus
111
PBC diagnosis
- Cholestatic liver picture (elevated ALP and GGT) - Positive Antimitochondrial antibody (AMA) - MRCP
112
PBC Tx
- Ursodeoxycholic acid (Urso): improves pruritus, slows progression - Liver transplant
113
Primary Sclerosing Cholangitis (PSC)
- More common in men | - 70% of patients have IBD (UC)
114
PSC pathology
- Progressive, diffuse inflammation and fibrosis of hepatic ducts leads to hardening and narrowing and liver damage - Higher risk of developing cholangiocarcinoma
115
PSC symptoms
- Profound fatigue | - Pruritus
116
PSC diagnosis
- Cholestatic picture (elevated ALP and GGT) | - ERCP – Gold standard
117
PSC Tx
- Progression cannot be halted | - Liver transplant only known cure
118
Budd Chiari pathology
- Hepatic venous outflow obstruction due to hypercoagulable state, tumor, abscess, vascular anomaly, webs, strictures, etc.
119
Budd Chiari symptoms
- RUQ pain and tenderness | - Ascites
120
Budd Chiari diagnosis
- US/MRI show occlusion or absence of flow in the hepatic veins or IVC
121
Budd Chiari Tx
- Treat ascites and underlying disorder
122
Portal hypertension complications
- Ascites - Spontaneous bacterial peritonitis - Hepatorenal syndrome - Varices - Hepatic encephalopathy - HCC/Hepatoma - Coagulopathy - Jaundice
123
Ascites (portal HTN comp.)
- Transudate (low protein & specific gravity) - PE: + shifting dullness, + fluid wave - Rx: sodium intake restriction, diuretics, therapeutic paracentesis if severely symptomatic
124
Spontaneous bacterial peritonitis (portal HTN comp.)
- Infection of ascites fluid w/o an identifiable source - S&S: Fever, abd pain, change in mental status - Dx: Ascites fluid - PMNs > 250 - Rx: cefotaxime (3rd gen cephalosporin) - Prophylaxis: ciprofloxacin or Bactrim
125
Hepatorenal syndrome (portal HTN comp.)
- Renal failure due to severe renal vasoconstriction | - High mortality
126
Varices (portal HTN comp.)
- 30% mortality with each bleed
127
Hepatic encephalopathy (portal HTN comp.)
- Patho: toxins (ammonia) are not cleared by the liver - S&S: waxing, waning alteration in mental status Asterixis, confusion, personality changes --> somnolence --> coma - Rx: Lactulose
128
HCC/Hepatoma (portal HTN comp.)
- Dx: elevated AFP
129
Coagulopathy (portal HTN comp.)
- Liver does not synthesize clotting factors - Dx: Vit K deficiency (II, VII, IX and X) - Prolonged PT/INR (measures liver synthetic function)
130
Jaundice (portal HTN comp.)
- Hyperbilirubinemia - Hemolysis - Decreased ability for conjugation - Impaired excretion - Biliary obstruction
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