11) GI (Part 1) Flashcards
1
Q
Zenker’s diverticulum pathology
A
- Weakness in posterior pharyngeal wall at pharyngoesophageal junction due to loss of elasticity of UES
2
Q
Zenker’s diverticulum symptoms
A
- Dysphagia
- Halitosis
- Choking
3
Q
Zenker’s diverticulum diagnosis
A
- Barium esophagram
4
Q
Zenker’s diverticulum Tx
A
- Cricopharyngeal myotomy with or without diverticulectomy
- Surgical excision of diverticula
5
Q
Achalasia pathology
A
- Motor disorder
- Absence of ganglion cells of Auerbach’s plexus (Myenteric plexus)
6
Q
Achalasia symptoms
A
- Gradual, progressive dysphagia for solids & liquids
- Regurgitation of undigested food
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
8
Q
Achalasia Tx
A
- Endoscopy guided botox injection
- Pneumatic dilation
- Surgical myotomy (modified Heller cardiomyotomy )
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
10
Q
Diffuse esophageal spasm symptoms
A
- Often presents as chest pain
11
Q
Diffuse esophageal spasm diagnosis
A
- Corkscrew/rosary bead esophagus on barium swallow
12
Q
Diffuse esophageal spasm Tx
A
- Nitroglycerin SL
- CCBs
- Stress reduction
- Avoid very cold or hot fluids
13
Q
Scleroderma pathology
A
- Motor disorder
- Patchy smooth muscle atrophy with fibrosis, with ensuing decreased esophageal contractility and absence of resting LES tone.
14
Q
Scleroderma symptoms
A
- Dysphagia, odynophagia
- Chronic reflux due to incompetent LES
- Decreased motility
15
Q
Scleroderma diagnosis
A
- Stricture of the distal esophagus on barium esophogram
16
Q
Scleroderma Tx
A
- PPI’s
- Promotility agents
- Dilatation of stricture prn
17
Q
Esophagitis
A
- Seen in immunosuppressed pts
- Odynophagia, dysphagia, and chest pain
18
Q
Esophagitis diagnosis
A
- Endoscopy with biopsy
- Seen with candida, CMV, and HSV
19
Q
Esophagitis from candida
A
- Yellow, white patches adhere to mucosa
- Tx with PO antifungal agents (fluconazole, itraconazole)
20
Q
Esophagitis from CMV
A
- Large, linear ulcers (furrows)
- Tx with antiviral agents if immunosupressed (acyclovir, famciclovir, valacyclovir)
21
Q
Esophagitis from HSV
A
- Multiple, shallow “volcanic shaped” ulcers
- Tx with antiviral agents (valacylovir, acyclovir)
22
Q
Causes of pill-induced esophagitis
A
- NSAIDS
- KCl tabs
- Quinidine
- Po bisphosphanates (alendronate & risedronate)
- Iron
- Antibiotics (doxycycline, tetracycline, minocycline, clindamycin, trimethoprim-sulfamethoxazole)
23
Q
Pill-induced esophagitis symptoms
A
- Dysphagia
24
Q
Pill-induced esophagitis diagnosis
A
- Endoscopy
- Shallow or deep ulcers
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
28
Eosinophilic esophagitis symptoms
- Similar to GERD
| - Seasonal allergy sxs (rhinorrhea, sneezing, etc)
29
Eosinophilic esophagitis diagnosis
- EGD with biopsy (extensive eosinophilic infiltration with mast cells, basophils; basal cell hyperplasia)
30
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
32
Mallory-Weiss Tear symptoms
- Hematemesis
33
Mallory-Weiss Tear diagnosis
- EGD
34
Mallory-Weiss Tx
- Fluid resuscitation, blood transfusion prn
| - Endoscopic hemostatic therapy in pts with continuous active bleeding
35
Esophageal Neoplasms
- Squamous cell carcinoma
| - Adenocarcinoma (seen more often)
36
Squamous cell carcinoma most common causes
- Cigarette smoking
| - Chronic ETOH use
37
Adenocarcinoma most commonly associated with
- Barrett's Esophagus
38
Esophageal neoplasms symptoms
- Progressive dysphagia
| - Weight loss
39
Esophageal neoplasms diagnosis
- EGD
| - CT for staging
40
Esophageal neoplasms Tx
- Surgery +/- XRT, Chemotherapy
- Ablation
- Esophageal stent for palliation of sxs
41
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
42
Barrett's Esophagus diagnosis
- EGD with biopsy
43
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
46
Esophageal stricture (Schatzki Ring) symptoms
- "steakhouse syndrome"
| - May present with non-progressive dysphagia for solids
47
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
75
Choledocholithiasis may present as
- Incidental finding
- Biliary colic
- Obstructive jaundice
- Cholangitis
- Pancreatitis
76
Cholangitis usually presents as
- Fever
- RUQ pain
- Jaundice (Charcot's triad)
77
Choledocholithiasis/Cholangitis diagnosis
- Abd ultrasound
| - ERCP to visualize common bile duct stones
78
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
81
Hep A Tx and prevention
- Treat symptomatically
| - Prevent w/ Hep A vaccine
82
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
104
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
