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Internal Medicine > Kaplan IM - Gastroenterology > Flashcards

Kaplan IM - Gastroenterology Flashcards

1
Q

What is the presentation of GERD?

A
  1. Substernal chest pain without cardiac disease
  2. Chronic cough
  3. Belching
  4. Metallic or sour taste
  5. Wheezing without reactive airway disease
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2
Q

Mention some major risk factors for GERD.

A
  1. Obesity –> BMI>28.
  2. Hiatal hernia
  3. Hypercalcemia –> Ca is 2nd messenger for gastrin.
  4. Zollinger-Ellison
  5. Medications –> Prednisone
  6. Motility disorders –> Scleroderma, gastroparesis (DM neuropathy)
  7. Cigarette smoking
  8. Xerostomia
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3
Q

What is the best initial test for GERD?

A

PPI administration –> also therapeutic.

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4
Q

What happens if after 4-6 weeks treatment failure of GERD with PPIs occurs?

A

The most accurate test is a 24h pH monitoring.

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5
Q

What indicates endoscopy in GERD?

A

When symptoms persist after maximal therapy + In alarm symptoms:

  1. Dysphagia
  2. Odynophagia
  3. GI bleeding or anemia
  4. Weight loss
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6
Q

When is 24h pH monitoring indicated?

A
  1. Asthma begins as an adult in the setting of GERD.
  2. Hoarseness persists for a prolonged duration.
  3. Sleep apnea is a comorbid finding
  4. Medical treatment has failed.
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7
Q

What are the 3 steps in the treatment of GERD?

A
  1. Lifestyle modifications
  2. Medical therapy
  3. Surgical treatment
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8
Q

What lifestyle modifications can be done to treat GERD?

A
  1. Elevate the head of the bed
  2. Stop tobacco, caffeine, chocolate, alcohol, and peppermint
    - -> ALL reduce lower esophageal sphincter pressure.
  3. Don’t sleep within 3 hours of a meal, when acid production in the stomach is at a peak.
  4. Lose weight.
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9
Q

What is the medical therapy for GERD?

A

PPIs and H2 blockers.

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10
Q

What percentage of patients is treated with H2 blockers?

A

Only 50-70%.

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11
Q

What do the antacids provide?

A

Short-term relief in only 20% of cases.

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12
Q

What is the surgical treatment of GERD?

A
  1. Nissen fundoplication

2. Transoral incisionless fundoplication (TIF) endoscopically rebuilds the LES through the esophagus.

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13
Q

What is the difference between dysphagia and odynophagia?

A

Dysphagia –> Difficulty shallowing.

Odynophagia –> Painful shallowing.

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14
Q

What is the probably the underlying cause of dysphagia in young patients and in old ones?

A

Young –> Secondary to a motility disorder.

Old –> Stroke is a more common cause.

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15
Q

What is probably the underlying cause in odynophagia?

A

Typically in the setting of an infectious process and requires biopsy during EGD.

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16
Q

Mention some causes of dysphagia.

A
  1. Achalasia
  2. Cancer
  3. Peptic strictures - rings from acid exposure.
  4. Zenker diverticulum - halitosis.
  5. Esophageal spasm
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17
Q

What is the type of dysphagia in achalasia?

A

Solids and liquids.

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18
Q

What is the etiology of achalasia?

A

Idiopathic and Chagas.

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19
Q

What is the best initial test in achalasia?

A

Barium shallow with a “Bird’s beak” sign + massively dilated esophagus.

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20
Q

What is the most accurate test in dysphagia caused by achalasia?

A

Esophageal manometry shows high LES pressure with shallowing and peristalsis.

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21
Q

What is the best therapy for dysphagia caused by achalasia?

A
  1. Pneumatic dilation
  2. LES injections of botulinum toxin type A
  3. Heller myotomy
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22
Q

What type of dysphagia do we see with esophageal cancer?

A

Progressive worsening from solids to liquids.

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23
Q

What is the etiology of esophageal cancer?

A
  1. Long-standing GERD
  2. Alcohol
  3. Tobacco
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24
Q

What is the best initial test for dysphagia caused by esophageal cancer?

A

EGD with biopsy and further imaging (CT scan, PET, ultrasound) for staging.

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25
Q

What is the most accurate test for dysphagia caused by esophageal cancer?

A

EGD - in cancer tissue biopsy only if definitive.

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26
Q

What is the best therapy for dysphagia caused by esophageal cancer?

A

Surgical resection and 5-fluorouracil therapy +/- radiation.

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27
Q

What type of dysphagia do we see with peptic strictures (rings from acid exposure)?

A

Solids or liquids.

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28
Q

What is the etiology of peptic strictures?

A

Long standing GERD.

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29
Q

What is the best initial test for dysphagia associated with peptic strictures?

A

Barium study.

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30
Q

What is the most accurate test for dysphagia associated with peptic strictures?

A

EGD is diagnostic and therapeutic.

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31
Q

What is the best therapy for dysphagia associated with peptic strictures?

A

Pneumatic dilation.

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32
Q

What type of dysphagia is associated with Zenker diverticulum (associated with halitosis)?

A

Solids and liquids.

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33
Q

What is the etiology of Zenker diverticulum?

A

Congenital.

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34
Q

What is the best initial test for Zenker diverticulum?

A

Barium study.

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35
Q

What is the most accurate test for dysphagia associated with Zenker diverticulum?

A

Barium study.

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36
Q

What is the best therapy for dysphagia associated with Zenker diverticulum?

A

Surgical resection or endoscopic stapling.

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37
Q

What type of dysphagia is associated with esophageal spasm?

A

Acute difficulty in shallowing solids and liquids with chest pain.

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38
Q

What is the etiology of esophageal spasms?

A

Diffuse, uncoordinated esophageal contractions.

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39
Q

What is the best initial test for dysphagia associated with esophageal spasms?

A

Barium study at time of attack showing a “corkscrew” esophagus.

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40
Q

What is the most accurate test for dysphagia associated with esophageal spasms?

A

Manometry in the setting of clinical symptoms.

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41
Q

What is the best therapy for esophageal spasms?

A

Ca channel blockers.

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42
Q

Mention some causes of esophagitis.

A
  1. Candidiasis
  2. CMV
  3. HSV
  4. Pill esophagitis
  5. Eosinophilic esophagitis
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43
Q

What are the signs and symptoms of esophagitis due to candida?

A

Dysphagia + Odynophagia.

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44
Q

What is the diagnostic test for esophagitis due to candida?

A

Treat patients with AIDS who have <100 CD4 cells with fluconazole.

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45
Q

What are the signs and symptoms of esophagitis due to CMV?

A

Dysphagia and odynophagia in an immunocompromised patient.

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46
Q

What is the diagnostic test for CMV esophagitis?

A

EGD with biopsy with viral cultures.

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47
Q

What is the best therapy for CMV esophagitis?

A

Ganciclovir or foscarnet.

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48
Q

What are the signs and symptoms of HSV esophagitis?

A

Dysphagia and odynophagia in an immunocompromised patient.

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49
Q

What is the diagnostic test for HSV esophagitis?

A

EGD with biopsy with viral cultures.

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50
Q

What is the best therapy for HSV esophagitis?

A

Acyclovir.

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51
Q

What are the signs and symptoms of pill esophagitis?

A

New-onset dysphagia and odynophagia in a patient on biphosphonates or doxycycline.

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52
Q

What is the diagnostic test in pill esophagitis?

A

EGD to rule out other causes.

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53
Q

What is the therapy in pill esophagitis?

A

Prevention with copious water with pills and sitting up 3 hours postingestion.

54
Q

What are the signs and symptoms of eosinophilic esophagitis?

A

Dysphagia and odynophagia in a young patient with atopy and normal motility.

55
Q

What is the diagnostic test for eosinophilic esophagitis?

A

EGD with biopsy followed by allergen testing to identify causative agent.

56
Q

What is the therapy for eosinophilic esophagitis?

A

Pneumatic dilatation + oral corticosteroid therapy.

57
Q

What are the 4 levels of findings in which the biopsies for Barrett esophagus are categorized?

A
  1. Non-dysplastic or Barrett esophagus –> Give PPIs and repeat EGD in 3 years.
  2. Low-grade dysplasia –> Give PPIs and repeat EGD in 3-6 months.
  3. High-grade dysplasia –> Surgical resection.
  4. Carcinoma –> Surgical resection.
58
Q

How is esophageal perforation caused?

A

By a sudden increase in intraluminal esophageal pressure with negative intrathoracic pressure caused by vomiting that leads to a full thickness tear.

59
Q

With what can esophageal perforation present?

A
  1. Severe retrosternal chest pain –> begins shortly after vomiting.
  2. Odynophagia + hematemesis.
  3. Crunching, rasping around, synchronous with the heartbeat from subcutaneous emphysema.
  4. Radiation of the pain to the left shoulder.
60
Q

What is the most accurate test for esophageal perforation?

A

Gastrografin esophogram –> will reveal extravasation of contrast outside the esophageal lumen.

61
Q

What is the management of esophageal perforation?

A
  1. Closure of the perforation is done surgically with debridement of the mediastinum.
  2. Endoscopic stents can be placed to close the perforation in patients non amenable to surgery.
62
Q

What is the presentation of Mallory-Weiss syndrome?

A

MUCOSAL tear due to vomiting that occurs commonly at the GE junction.
Presents with:
1. Chest pain
2. Hematemesis
3. Will not have subcutaneous air
Commonly occurs in alcoholics and bulimics.

63
Q

Abdominal pain that is worse after eating indicates what?

A

Gastric ulcer.

64
Q

Abdominal pain that is better with eating indicates what?

A

Duodenal ulcers.

65
Q

Mention the major risk factors for peptic ulcer disease?

A
  1. H.pylori infection
  2. NSAIDs
  3. Burns - Curling ulcers
  4. Head injury - Cushing ulcers
  5. IBD - Crohn
  6. Cancer - tumor itself becomes ulcerated
  7. Mechanical ventilation - stress gastritis
66
Q

What is the prevalence of having an ulcer with NSAID use?

A

20%.

67
Q

Are alcohol and smoking risk factors for peptic ulcer disease?

A

No - But they prevent ulcer HEALING.

Do NOT directly cause ulcers.

68
Q

What is the clinical presentation of peptic ulcer disease?

A

Patient presents with gnawing abdominal pain localized to epigastrium.
Severe ulcers may also have gastric outlet obstruction causing early satiety + bleeding leading to anemia and heme-positive stools.
MCC of epigastric pain is non-ulcer dyspepsia.

69
Q

Is there a way to be certain of the etiology of epigastric pain without endoscopy?

A

No way.

70
Q

What must be done in all vented patients?

A

Must be of PPIs to prevent stress ulcers.

71
Q

How high is the risk of a gastric ulcer to proceed to cancer?

A

4%.

72
Q

What is the mainstay of diagnosis in patients with suspected PUD?

A

Upper endoscopy.

73
Q

Why are biopsies necessary with gastric ulcer?

A

To exclude cancer.

74
Q

How do we make the diagnosis of H.pylori?

A

If endoscopy and biopsy are performed, NO FURTHER TESTING.
If endoscopy is not performed:
1. Serology
2. Breath testing and stool antigen

75
Q

What diagnostic methods for H.pylori are highly specific ONLY for active infection?

A

Breath testing and stool antigen.
Neither of them is routine.
Useful as a test of cure after treatment, unless there is recurrence of symptoms.

76
Q

What may affect the sensitivity of breath testing and stool antigen for H.pylori?

A
  1. PPIs
  2. Bismuth
  3. Antibiotics
77
Q

What is the treatment of peptic ulcer disease?

A
  1. Discontinue NSAIDs
  2. Treat H.pylori with triple therapy - PPI, clarithromycin, and amoxicillin.
  3. Recurrent/persistent symptoms are likely due to either noncompliance or resistance.
  4. Repeat endoscopy may be warranted if symptoms do not resolve.
  5. Gastric ulcer must be re-scoped to ensure resolution of the ulcer.
78
Q

What is the ONLY 100% accurate way to exclude cancer even if the biopsy is normal?

A

Gastric ulcer must be re-scoped to ensure resolution of the ulcer.

79
Q

What is the presentation of Zollinger-Ellison syndrome?

A
  1. Severe abdominal pain
  2. Anemia
  3. Watery diarrhea
  4. Weight loss –> acid inactivates lipase
  5. Anorexia
80
Q

When should we suspect Zollinger-Ellison syndrome in those with PUD?

A
  1. Multiple large ulcerations >1cm in size.
  2. Ulcerations beyond the ligament of Treitz.
  3. Symptoms after recurrent HP treatment.
81
Q

Will secretin have any effect in Zollinger-Ellison?

A

No effect.

82
Q

What are the most accurate tests for Zollinger-Ellison syndrome?

A
  1. Endoscopic ultrasound (EUS)

2. Nuclear somatostatin scan

83
Q

What advantage does EUS have?

A

Has the advantage of being able to directly gain tissue samples and endoscopically tattoo the lesion with ink for future surgical resection.

84
Q

What is the treatment for Zollinger-Ellison?

A

Localized –> Surgical resection.

Metastatic disease –> Lifelong PPI + chemotherapy + Tumor embolization (if hepatic) + octreotide.

85
Q

How long does H.pylori treatment must go?

A

10-14 days.

86
Q

What percentage of patients have H.pylori in their GI tracts?

A

More than 50%.

87
Q

With what cancers is H.pylori associated?

A

1-2% lifetime risk of stomach canceer + less than 1% risk of gastric MALT lymphoma.

88
Q

What percentage of MALT lymphomas of the stomach are associated with H.pylori?

A

80%.

89
Q

What are the 4 major methods of testing for H.pylori?

A
  1. Stool antigen testing –> used to evaluate for disease eradication.
  2. Urease breath testing –> used to evaluate for disease eradication.
  3. Serology is HIGHLY SENSITIVE –> cannot distinguish between previous infection and active infection.
  4. EGD with biopsy and Giemsa staining is the most accurate test.
90
Q

What is the most accurate test for diagnosing H.pylori?

A

EGD with biopsy and Giemsa staining.

91
Q

What is the treatment for H.pylori?

A

PPI + Clarithromycin + Amoxicillin for 14 days.

If allergic to penicillin –> Replace amoxicillin with metronidazole.

92
Q

Every patient who starts infliximab must have what?

A

A PPD to detect latent TB.

93
Q

Mild diarrhea is self-limiting. What defines severe diarrhea?

A
  1. Fever
  2. Abdominal pain
  3. Hypotension
  4. Tachycardia
  5. Blood in the stool (most important diagnostic criteria)
94
Q

What is the best initial test for diarrhea?

A

Fecal leukocytes.

95
Q

What is the most accurate test for diarrhea?

A

Stool culture.

96
Q

What is the treatment of diarrhea?

A

Fluid resuscitation antibiotics (fluoroquinolones) are useful for acute traveler’s diarrhea and for severe disease.

97
Q

Mention some causes of bloody diarrhea.

A
  1. C.jejuni
  2. E.coli
  3. Salmonella
  4. Shigella
  5. Yersinia
  6. Vibrio parahemolyticus
  7. Giardia
  8. Entamoeba histolytica
98
Q

What is the cause of C.jejuni infection?

A
  1. Fecal-Oral transmission

2. Raw meat

99
Q

What are the features of C.jejuni diarrhea?

A
  1. MCC of gastroenteritis
  2. Febrile illness
  3. Associated with Guillain-Barre + reactive arthritis
  4. Left lower quadrant mimicking diverticulitis
  5. Usually self-limited after 1 week
100
Q

What is the treatment of C.jejuni diarrhea?

A

Macrolides - RESISTANT to fluoroquinolones.

101
Q

What is the cause of E.coli diarrhea?

A
  1. Undercooked beef
  2. Fresh product
  3. Unpasteurized dairy product
  4. Petting zoos
102
Q

What are the 3 main forms of E.coli diarrhea?

A
  1. O157:H7 –> associated with HUS –> NEVER GIVE ANTIBIOTICS.
  2. ETEC –> Traveler’s diarrhea.
  3. Enterohemorrhagic.
103
Q

What is the cause of Salmonella diarrhea?

A

Chicken and eggs.

104
Q

What is important to keep in mind about salmonella diarrhea?

A

Usually self-limited.

105
Q

What is the cause of shigella diarrhea?

A

Shiga toxin: most severe.

106
Q

With what is shigella diarrhea associated?

A

With reactive arthritis and daycare settings.

107
Q

What is the cause of Yersinia diarrhea?

A

Rodent urine or feces and old creamy pastries.

108
Q

What is important to keep in mind about Yersinia diarrhea?

A

RLQ pain mimicking appendicitis.

109
Q

What is the cause of V.parahemolyticus diarrhea?

A

Undercooked seafood, usually oysters.

110
Q

What are the features of V.parahemolyticus diarrhea?

A

Look for oysters eaten in warm weather environments.

111
Q

What is the cause of Giardia diarrhea?

A
  1. Drinking fresh water

2. Detected with 3 O&P studies or 1 ELISA antigen

112
Q

How do we treat Giardia?

A

With metronidazole.

113
Q

What is a possible complication of Giardia diarrhea?

A

Liver abscesses.

114
Q

What is the cause of E.histolytica diarrhea?

A

Travelers in endemic areas.

115
Q

Mention some causes of Non-bloody diarrhea?

A
  1. Viral gastroenteritis
  2. S.aureus
  3. Tropheryma whippelii
  4. Strongyloides
  5. B.cereus
  6. Scombroid food poisoning
  7. Cryptosporidiosis
  8. VIPoma/ glucagonoma and Zollinger-Ellison syndrome
116
Q

What is the cause of viral gastroenteritis?

A
  1. Rotavirus –> Daycare setting

2. Norwalk (Noro) virus –> Cruise ship gastroenteritis

117
Q

What is the feature of viral gastroenteritis?

A

Self-limiting.

118
Q

What is the cause of S.aureus diarrhea?

A

Creamy foods such as mayonnaise.

119
Q

What are the features of S.aureus diarrhea?

A

Vomiting and diarrhea within 6-8 hrs of ingestion due to toxin.

120
Q

What is the cause of Tropheryma whippelii diarrhea?

A

UNKNOWN reservoir.

121
Q

How do we diagnose Tropheryma whippelii?

A

EGD biopsy shows PAS-positive macrophages.

122
Q

What is the treatment for Tropheryma whippelii?

A

Antibiotics for 1 year or more.

123
Q

What is the cause of Strongyloides diarrhea?

A

Ascends through the skin of the foot to the lung, and then is shallowed.

124
Q

What are the features of Strongyloides diarrhea?

A
  1. Diarrhea
  2. Epigastric pain
  3. Anemia
  4. Eosinophilia
125
Q

What is the treatment for Strongyloides?

A

Ivermectin or thiobendazole.

126
Q

What is the cause of B.cereus diarrhea?

A

Refried rice.

127
Q

What happens with B.cereus diarrhea?

A

Nausea and vomiting within 2 hours of ingestion.

128
Q

What is the cause of Scombroid food poisoning?

A
  1. Tuna
  2. Mackerel
  3. Mahi-Mahi
129
Q

What happens with Scombroid food poisoning?

A

Diarrhea within 10 minutes of ingestion.

130
Q

How do we treat Scombroid food poisoning?

A

With antihistamines.

131
Q

Which is the MC GI disorder affecting Americans?

A

Esophageal disease –> 44% of population suffering from “heartburn” at least once a month.

Internal Medicine (107 decks)

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