3 Feb 24

Question 1

Autoimmune metaplastic atrophic gastritis mechanism

Answer 1

Antibodies against parietal cells
(Causing atrophy and metaplasia of gastric corpus , hypochlorhydria , unchecked gastrin production)

Antibodies towards intrinsic factor
(B12 def)

Question 2

Female autoimmune history gastric features macrocytic anemia

Answer 2

Think about AMAG
Autoimmune metaplastic atrophic gastritis.

Question 3

CF of autoimmune metaplastic atrophic gastritis

Answer 3

Post prandial abd pain
Bloating
Nausea
Heartburn
Regurg
Elevated serum gastrin
Dec stomach acid 👉🏼reduced Fe bioav
Iron def anemia

Question 4

Complications of AMAG

Answer 4

Inc risk for gastric adenocarcinoma
(Routine endoscopy needed)

Question 5

Cause of inc BUN and Cr in Upper GIT bleed

Answer 5

Inc urea production from intestinal breakdown of Hb and inc urea reabsorption in proximal tubule due to associated hypovolemia.

Inc BUN/Cr ratio

Question 6

Criteria of transfusion in pts with UGIB

Answer 6

Stable pts <7 Hb
Unstable Acute coronary pts <9 Hb
Active bleed pts with Hypovolemia give pack cells as Hb levels drop massively if crystalloid solutions are given

Whole blood is given for massive hemorrhage eg trauma.

Question 7

Angiodysplasia of colon CF

Answer 7

🎱Episodic painless GI bleed
🎱Dilated submucosal veins and AV malformations
🎱Inc incidence after 60y
🎱Can occur anywhere in GIT mainly Rt colon
🎱Easily missed on colonoscopy

🎱Associated with advanced CKD and vWD
🎱Also common with Aortic stenosis due to acquired vW factor def (disruption of vWmultimers as they traverse the turbulent valve space induced by AS )

🎱Bleeding remits after valve replacement.

Question 8

Angiodysplasia ttt and dx

Answer 8

Dx : endoscopy/colonoscopy

Ttt: No ttt req in A/S cases
Anemics or those with gross occult
Bleed are treated with endoscopy and cautery

Question 9

Benefit of octreotide in UGIB

Answer 9

Somatostatin analogue (octreotide ) inhibits release if vasodilator hormones causing splanchnic vasoconstriction and decrease portal flow.

Alternate: terlipressin (vasopressin analogue)

Question 10

Criteria to transfuse blood in GIbleed pt

Answer 10

Keep Hb >7 in stable pts
Hb>9 in pts with acute coronary dx

Question 11

Duodenal ulcer vs gastric ulcer

Answer 11

DU pain worse on empty stomach and improves with food (due to alkaline fluid secretion in duodenum)

Gastric ulcer pain is worse after eating (increased acid secretion)

Question 12

Cause of duodenal ulcer

Answer 12

Hpylori
NSAIDS

Question 13

Ttt of duodenal ulcer due to Hpylori

Answer 13

🛖antisecretory therapy = PPI
🛖Amoxicillin plus clarithromycin

Question 14

Achalasis in an old patient with significant weight loss

Answer 14

Pseudoachalasia
Due to cancer

Question 15

Primary achalasia vs pseudoachalasia

Answer 15

Primary achalasia:

      Younger pt 20-50y
      Insiduous onset 
      Mild weight loss
      Endoscopy shows normal mucosa with dilated esophagus 
      Closed LES which is easily traversed by scope 

Psudoachalasia :

     Age >60
     Rapid onset <6mo
     Sig weight loss 
     Mucosal lesions on endoscopy
     LES is not traversed by a scope as it is obstructed by tumor.

Question 16

RF of pseudoachalasia

Answer 16

🏀Tobacco use
🏀Presence of alarm features
🏀Wide mediastinum due to tumor mets (lymph nodes) or local tumor invasion.

Dx
Endoscopy

Question 17

Zenker diverticulum and pneumonia

Answer 17

Regurgitation of undigested food or medications several hours after eating leads to aspiration and recurrent aspiration pneumonia

Question 18

Mallory weiss syndrome etiology and CF

Answer 18

Etiology:

      Forceful retching 
      Mucosal tear 
      Submucosal venous or arterial plexus bleeding 

CF :

     Epigastric /back pain 
     Hematemesis (bright red or coffee ground ) 
     Possible hypovolemia

Question 19

DX and ttt of MW syndrome

Answer 19

Dx : Upper GI endoscopy

Ttt: Acid suppression
Most heal spontaneously
For persistent bleed ttt with endoscopic electrocoagulation or local injection of epinenephrine

Question 20

Boerhaave syndrome etiology and CF

Answer 20

Etiology :

       Forceful retching 
       Transmural tear 
       Spillage of esophageal air /fluid 

CF :

       Chest /back/ epigastric pain
       Crepitus , crunching sound (hamman sign) 
       Odynophagia , dyspnea,  fever , sepsis

Question 21

Workup for boerhaave and ttt

Answer 21

Dx: CXRay (pnemothorax , pneumomediastinum, pleural effusion)
Esophagography or CT with water soluble contrast.

Ttt:

        Acid suppression , Antibiotics , NPO
        Emergency surgical consult

Question 22

MW tear RF

Answer 22

Alcohol use disorder
Hiatal hernia

Question 23

Gastroschisis complication s

Answer 23

FGR :
Nutrition loss across exposed bowel

Oligohydramnios :
Blood and nutrients are shunted away from kidneys to vital organs (brain) causing dec fetal urine production and hence oligo .

Polyhydramnios:

   Continuous exp of intestines to Amniotic fluid causes chronic inflammation and edema causing intestinal thickening and reduced bowel motility . And even bowel obstruction. Resulting in polyhydramnios.

Question 24

Pyloric stenosis initial management

Answer 24

Babies who present with hypochloremic hypokalemic metabolic alkalosis due to prologed vomiting should have

IV rehydration and electrolyte replacement prior to pyloromyotomy to decrease risk of post operative apnea

Question 25

GERD in babies CF and Ttt

Answer 25

Physiologic GERD
A/S
Happy spitter
Reassure
Position therapy
High freq low vol feeds

Pathologic GERD
Failure to thrive
Sig irritability
Sandifer syndrome

     ttt; 
      Thick feed 
      Antacid 
      If severe esophageal ph probe monitoring and upper endoscopy

Question 26

Milk protein allergy CF and ttt

Answer 26

CF :
Regurg/vomiting
Eczema
Bloody stools

Ttt:
Elimination of dairy and soy from diet

Question 27

Pyloric stenosis CF and ttt

Answer 27

Projectile non bilious vomiting
Olive shaped abd mass
Dehydration
Weight loss

Ttt:
Abd USG
Pyloromyotomy

Question 28

Remedies for GERD babies

Answer 28

Freq small vol feeds
Hold infant upright 20-30 mins
Place infant prone while awake
Avoid inc abd pressure :
Tight diaper
Bringings knees to stomach

Improves by 6mo and resolves in 1y

Question 29

DD for a child who cant advance his diet from puree to solid. HO eczema

Answer 29

Neurologic dx
Anatomical abnormalities (stricture)
Developmental (autism)
Inflammatory. (Esophagitis)

Question 30

Esosinoplic esophagitis CF And ttt

Answer 30

Feeding dysfunction
Preference for soft foods
Dysphagia
Poor weight gain
Concomitant atopy (asthma , eczema)

Dx : endoscopy with biopsy
>15eosinophils /hpf

Ttt:

      Dietary modification (avoid triggers)
      PPIs 
      Topical(swallow) glucocorticoids 
      Feeding therapy (severe cases with meal anxiety and food avoidance )

Question 31

EE vs celiac dx

Answer 31

Celiac dx has diarrhea/constipation and abd pain /distension
Refusal to all foods is not typical

Question 32

Cause of volvulus in intestinal malrotation

Answer 32

Malrotation predisposes to midgut volvulus because arrest of normal gut rotation during fetal development results in narrow mesenteric base of intestine. This allows small bowel to twist freely around SMA

Question 33

Pyloric stenosis RF

Answer 33

👀Macrolide exposure
👀First born boy
👀Formula fed infants (slow gastric emptying which increased gastric burden causing pyloric muscle growth)

Question 34

Pyloric stenosis CF and exam

Answer 34

Age 3-5 w
Post prandial projectile vomiting followed by hunger
Hungry spitter
Non bilious vomit
Signs of dehydration( sunken fontanelle, dec skin turgor , delayed capillary refill)
Weight loss

▶️Classic olive shaped mass may not be always palpable.
▶️Visible peristalsis
▶️Normal abd exam