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Clinical Flashcards

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1
Q

Most potent acid inhibitor for GERD?

A

PPIs

-heals erosive esophagitis

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2
Q

Does the grade of esophagitis correlate with the degree of symptoms?

A

No

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3
Q

What is the main reason for GERD?

A

LES dysfunction

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4
Q

Causes of GERD?

A
  1. Defective esophageal clearance (dysmotility)
  2. Hiatal Hernia
  3. LES dysfxn (decreased pressure)
  4. Delayed gastric emptying
  5. Increased intrabdominal pressure (GPEG)
  6. Increased transient relaxation of LES
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5
Q

Typical GERD symptoms?

A
  • heartburn
  • regurgitation
  • difficulty swallowing
  • water brash: hyper salivation
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6
Q

Atypical GERD?

A
  • chronic cough
  • cavities
  • chest pain
  • hoarse
  • asthma
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7
Q

Complications of GERD?

A
  • bleeding
  • stricture
  • ulcers
  • Barrett’s
  • Cancer
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8
Q

Barrett’s esophagus?

A

metaplastic columnar epithelium replaces stratified squamous

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9
Q

Factors that Increase risk of GERD?

A
  • nocturnal acid
  • age
  • white
  • male
  • obesity
  • tobacco
  • family history
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10
Q

Factors that decrease risk of GERD?

A

CagA+ H. pylori

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11
Q

Middle aged white obese male with reflux for 20 years.

  1. Diagnosis?
  2. Treatment?
A
  1. GERD

2. PPI for 3 weeks then endoscopy

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12
Q

Factors that increase risk of esophageal squamous cell ca?

A
  • smoking
  • alcohol
  • low veggie intake
  • hot liquids
  • achalasia
  • lye ingestion
  • Tylosis (hyperkeratosis of palms and feet)
  • Bisphosphonates
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13
Q

Treatment of esophageal squamous cell ca?

A
  1. Endoscopy with biopsy
  2. CT/MRI for metastases
  3. Endoscopic ultrasound if negative
  4. chemo/radiation
  5. Palliation
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14
Q

Most common esophageal cancer?

A

Adenocarcinoma of lower 1/3

  • arise from BE
  • nocturnal heartburn is risk factor
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15
Q

Clinical EoE in adults?

A
  1. Dysphagia
  2. Food impaction
  3. Heartburn
  4. Regurgitation
  5. Chest pain
  6. Odynophagia
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16
Q

Clinical EoE in children?

A
  1. abdominal pain
  2. Heartburn
  3. Regurgitation
  4. N/V
  5. Dysphagia
  6. Failure to thrive
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17
Q

Linear furrows, exudates, and concentric rings in esophagus?

A

Eosinophilic Esophagitis

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18
Q

Eoe complications?

A
  • longitudinal rent

- perforation

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19
Q

Histo diagnosis of EoE?

A

> 15 eosinophils per HPF on biopsy

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20
Q

Treatment of EoE?

A
  1. elimination diet
  2. PPI
  3. Swallow steroids for adults (Fluticasone)
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21
Q

Pathophys of achalasia?

A
  • degeneration of neurons in esophageal wall leads to lack of inhibition of LES so LES cannot relax and loss of peristalsis in distal esophagus
  • caused by Chagas (trypanosome cruz)
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22
Q

Dysphagia to solids and liquids with regurgitation onto pillow at night?

A

achalasia

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23
Q

How to diagnose achalasia?

A
  • barium swallow shows dilated esophagus and beak like narrowing
  • manometry shows elevated LES resting pressures
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24
Q

Treatment for achalasia?

A
  • nitrates
  • ca blockers
  • botulinum
  • pneumatic balloon
  • myotomy
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25
Boerhaave syndrome?
- sudden increase in esophageal pressure with negative intrathoracic pressure causes perforation - severe retching - severe retrosternal chest pain
26
How to diagnose esophageal perforation?
- CXR shows free air - CT - gastrograffin swallow - EGD if surgery
27
HIV+ patient with odynophagia, who inhales corticosteroids. EGD shows white mucosal plaques down esophagus. 1. Diagnosis? 2. Treatment?
1. Candidiasis | 2. Fluconazole
28
Prophylaxis of esophageal varices?
- nonselective beta blockers | - EVL
29
Treatment of esophageal varices hemorrhage?
- EVL - blood with clotting factors - Octreotide (somatostatin) to decrease portal pressures - Quinolones or Ceftriaxone - balloon - surgery - TIPS
30
Nutcracker esophagus?
>220 mmHg distal esophageal peristaltic pressures | -hypercholinergic
31
Complicated symptoms of GERD?
- dysphagia - odynophagia - bleeding
32
How should GERD be diagnosed?
clinically, no tests
33
Management of GERD?
1. weight loss 2. elevate bed 3. eliminate food triggers 4. PPI
34
Factors that predict poor response to medical therapy of GERD?
1. nocturnal reflux 2. LES dysfxn 3. mixed gastric and duodenal reflux 4. mucosal injury
35
Hiatal hernia causes?
1. Phrenesophageal ligament degeneration - aging - smoking 2. Increased intra-abdominal pressure - obesity (BMI > 30 increases risk 4.2) - straining
36
Types of hiatal hernias?
1. GE junction above diaphragm = most common 2. Fundus herniates above diaphragm 3. GE and Fundus herniate 4. GE, Fundus, and other organs herniate
37
Gold standard treatment of Hiatal hernias?
1. Nissen fundoplication - 360 degree wrap 2. Toupet - 270 degree 3. Dor - wrap anterior to esophagus
38
ADR of Nissen?
- flatulence | - adbominal distention
39
Old female with chronic DM presents with early satiety, epigastric pain, and vomiting of undigested food. Diagnosis?
1. Diabetic gastroparesis 2. pyloric stenosis 3. achalasia
40
If you suspect gastroparesis, what's your next step?
1. Rule out mechanical obstruction first | 2. Gastric Scintigraphy
41
Gastroparesis pathophys?
MMC and phasic antral motility are impaired
42
Most common cause of gastroparesis?
idiopathic
43
Protective factors of the stomach? causes of disruption?
1. mucous (acid) 2. hydrophobicity (h. pylori) 3. bicarbonate (NSAIDS) 4. blood flow (ischemia) 5. prostaglandins (NSAIDS)
44
Noninvasive tests for H. pylori?
- Urea breath test - Stool antigen - serology
45
When to test for H. pylori?
- active ulcer - history of ulcers - MALT - if going to be treated
46
Highest risk of PUD?
NSAIDS users with H. pylori
47
ZE?
- gastrinoma secreting hyper gastrin in duodenum (70%) or pancreas - PUD develops in duodenum (90%)
48
How to diagnose ZE?
- Fasting serum Gastrin levels (>1000 pg/mL) - gastric pH < 2 - Secretin test - screen for MEN1 (PTH, Ca, prolactin)
49
Causes of gastritis?
- infections - drugs - autoimmune hypersensitivity
50
Causes of gastropathy?
- drugs - bile reflux - stress - hypovolemia - chronic vascular congestion
51
Enlarged gastric folds Ddx?
- Chronic gastritis (lymphoid hyperplasia/h. pylori) - tumors - ZE - Menetrier's
52
Menetrier's?
- enlarged rugal folds (foveolar hyperplasia) - decreased acid (parietal atrophy) - protein losing gastropathy - hypoalbumin - associated with CMV and H. pylori
53
Most common benign tumor of stomach?
leiomyoma
54
Highest incidence of gastric cancer?
Japan
55
Volvulus?
- stomach rotates - organoaxial: greater curve swings up - mesenteroaxial: antrum rotates to the left
56
Cholesterol stones?
- monohydrate crystals - mucin - unconjugated Br
57
Black pigment stones?
- cirrhosis, hemolysis, TPN - unconjugated Br - calcium - mucin
58
Brown pigment stones?
- stasis, infection (radiolucent) - unconjugated - anaerobes - mcuin - ca salts
59
Gallstone pathophys?
1. Increased cholesterol and decreased bile salts causes supersaturation 2. central calcium nidus 3. GB stasis
60
Is a CT a good test for gallstones?
no unless calcified
61
MRCP for gallstones?
highly sensitive if stones > 1cm | -doesnt detect small stones
62
Best test for imaging gallstones?
1. EUS | 2. ERCP
63
Biliary colic from chronic cholecystitis?
- stone is in neck of cystic duct, intermittent obstruction - fibrosis and inflammation - shrunken GB and RA sinuses if recurrent - epigastric pain radiating to right shoulder
64
Ultrasound results for chronic cholecystitis?
hyper echoic foci with shadowing
65
Most common complication of gallstone disease?
Acute cholecystitis - 90% from chronically obstructed stone - young females
66
Pathophys of acute cholecystitis?
cystic duct is obstructed by gallstone which damages GB mucosa stimulating prostaglandin synthetase -secretions and inflammation with bacteria (50%)
67
40 year old female with RUQ pain, elevated Br (<4), and inspiratory arrest (murphys). 1. Diagnosis? 2. if Br >4?
1. Acute cholecystitis | 2. Choledocholithiasis
68
Ddx of acute cholecystitis?
- Appendicitis | - Pancreatitis
69
Choledocholithiasis?
stone in CBD
70
Patient with RUQ pain, fever, jaundice, hypotension, and confusion. ALT > 150. Elevated direct bilirubin. Diagnosis?
Choledocholithiasis with ascending cholangitis
71
Acalculous cholecystitis?
- GB inflammation without stones - elderly, HIV, vasculitis, infection, BMT - treat with antibiotics and cholecystectomy
72
Causes of acalculous cholecystitis?
- prolonged fasting - immobility (no CCK) - hemodynamic instability (ischemia)
73
Cholesterolosis?
accumulation of lipid in GB mucosa
74
Patient with epigastric pain that radiates to the back, N/V, and diarrhea. Labs show elevated lipase. Diagnosis?
Acute pancreatitis
75
Key histories for acute pancreatitis?
- Biliary disease - Chronic alcohol abuse - Binge drinking - HyperTG - Post-op - Cystic fibrosis
76
Xray of acute pancreatitis?
1. Colon cut off sign - edema of pancreas compressing on splenic flexure with distention and sympathetic ileus 2. Sentinel loop - due to ileus
77
Purtscher retinopathy?
thrombi in eye indicating acute pancreatitis
78
What enzyme is always elevated in acute pancreatitis?
Lipase | -amylase but not as specific
79
Why use abdominal ultrasound?
suspected biliary disease | -not used for pancreatitis
80
Why use MRCP?
noninvasive image of biliary and pancreatic ducts | -use if choledocholithiasis is suspected
81
Test done if acute pancreatitis is severe?
Abdominal CT
82
What is severe acute pancreatitis?
- severe inflammatory infiltrate - necrosis - gland dysfunction - multi organ failure - admitted to ICU
83
Ranson criteria for pancreatitis on admission?
- age 55 - WBC > 16,000 - Glucose > 200 - LDH > 350 - AST > 250
84
Ranson criteria within 48 hours?
- Hct drops >10% - BUN increases by 5 - Calcium < 8 - pO2 < 60 - Base deficit > 4 - Fluid sequestration > 6 L
85
Patient with epigastric pain, weight loss, steatorrhea, and DM. Low trypsinogen and high glucose. Diagnosis?
Chronic pancreatitis
86
Pathognomic test for chronic pancreatitis?
KUB and CT shows calcium deposits on pancreas and pseudocysts -ERCP is gold standard to diagnose but less invasive option is done first
87
Patient is having worsening symptoms after 4 weeks from bout of acute pancreatitis
Necrotizing pancreatitis
88
CT/MRI results of necrotizing pancreatitis?
Dead tissue will not take up IV contrast and appear black | -air indicates infection
89
Signs of necrotizing pancreatitis, hemorrhagic?
Cullen sign -bluish discoloration around umbilicus secondary to hemoperitoneum Grey Turner sign -red brown purple flank secondary to retroperitoneal blood
90
Treatment of acute pancreatitis?
1. NPO 2. IVF (D5W) 3. Analgesics 4. Imipenem Abx 5. TPN if Ranson >3
91
AST normal value? Where synthesized?
8-45 Liver, heart, muscles -found in mitochondria
92
ALT normal value? Where synthesized?
7-55 - 20-25 females - 30-35 males Liver cells -more specific to liver disease than AST
93
AST:ALT in a 2:1 ratio?
Alcoholic hepatitis
94
Patient with ALT/AST 10x higher than normal, asterixis, confusion, and prolonged PT.
Acute liver failure with encephalopathy
95
ALP normal value? Where made?
45-115 Made in liver and bones
96
ALP >4x normal and high GGT. Mild elevation of AST/ALT. Diagnosis?
cholestasis
97
High ALP and normal GGT. Diagnosis?
Bone disease
98
GGT normal value? Where made?
9-48 made in liver cells and biliary epithelial cells
99
LDH use?
122-222 useful for MI or hemolysis
100
Why does PT and INR increase in liver disease?
- decreased synthesis of clotting factors | - Vit k deficiency
101
Low albumin in hepatic test means?
chronic liver disease
102
Normal bilirubin levels?
0.2-1.2
103
Elevated bilirubin with normal ALP. Diagnosis?
genetic disorder or hemolysis
104
Elevated conjugated Br?
- biliary obstruction - intrahepatic cholestasis - liver injury
105
What conjugates Br?
UDP-glucuronosyltransferase
106
College student with fatigue and jaundice. High unconjugated Br. 1. Diagnosis? 2. Pathophys? 3. Treatment?
1. Gilbert Syndrome 2. Mild reduction in UDP-G 3. Phenobarbital
107
Infant 2 weeks after birth with extensive jaundice and increased unconjugated Br. Dies shortly after. Diagnosis?
Crigler Najjar Type 1 - lack of conjugating enzyme - Type 2 less severe
108
Patient with elevated conjugated Br, jaundice, and a black liver. Diagnosis?
Dubin johnson | -inability to transport Br to bile canaliculi
109
Patient with elevated conjugated Br and no black liver. Diagnosis?
Rotor
110
Patient with cirrhosis, DM, and hyperpigmentation of skin. Elevated Ferritin >500. Diagnosis? Pathophys? Treatment?
Hemochromatosis - HFE gene 282Y - increased intestinal iron absorption which is normally regulated by Hepcidin - treat with phlebotomy - women delayed symptoms due to menstruation
111
A1-AT function?
- produced in hepatocytes | - inhibits elastase
112
Most common deficient allele in A1-AT?
z allele results in emphysema and eventual cirrhosis
113
Child with jaundice, ascites, and poor nutrition. Diagnosis?
A1-AT
114
Adolescent with anorexia, ascites, and peripheral edema. Diagnosis?
A1-AT
115
Diagnosis of A1-AT? Treatment?
- serum A1-AT - PCR to detect Z - treat symptoms
116
40 year old female with pruritus, fatigue, hepatosplenomegaly, xanthomas, elevated ALP and IgM, and antimitochondrial antibodies. Diagnosis? Treatment?
Primary Biliary Cholangitis - T cell autoimmune interlobular duct damage - treat with Ursodiol - watch bone health
117
Man with ulcerative colitis, pruritis, and elevated ALP. Diagnosis?
Primary sclerosing cholangitis - fibrosis of intra and extra hepatic ducts - diagnose with cholangiography
118
Man who doesn't drink, has mildly elevated LFTs and hepatic steatosis. Diagnosis?
Nonalcoholic fatty liver disease - insulin resistance from obesity, DM, dyslipidemia, metabolic - no inflammation - inflammation seen in NASH
119
Young man with cirrhosis, Kayser fleisher rings around corneas, jaundice, and behavioral changes. Labs show decreased Ceruloplasmin and increased urine copper. Diagnosis? pathophys? Treatment?
Wilson disease - abnormal copper transport protein - autosomal recessive - treat with D-penicillamine, Trientine, or zinc to bind copper
120
First test if liver suggest cholestasis?
ultrasound - 95% sensitive for gallstones - noninvasive and cheap - may miss small lesions
121
Uses for CT?
- hepatomegaly - intrahepatic tumors - portal HTN - biliary tree dilation -it is noninvasive but is expensive, uses contrast, and radiation
122
Use of MRI?
most accurate for liver lesions but is expensive and contrast can cause kidney problems
123
Use of PET?
smaller lesions and metastatic disease
124
Use of Cholescintigraphy (HIDA)?
cholecystitis or gallstone
125
Use of MRCP?
intrahepatic and extra hepatic bile ducts for gallstones, strictures, or dilatation and is noninvasive
126
Use of ERCP?
invasive but more reliable than MRCP and can extract stones or insert stents -risk of pancreatitis
127
Use of PTC?
invasive evaluation of biliary tree | -risks fever, bacteria, peritonitis, hemorrhage
128
Treatment for fulminant hepatitis?
urgent transplant
129
Presentation of HAV?
Children asymptomatic Adults symptomatic
130
HBsAg+ for 6 months?
Chronic HBV
131
HBsAg-, HBcAb+, HBsAb+?
past HBV resolved, no vaccine
132
HBsAg-, HBcAb-, HBsAb+?
immune, no vaccine
133
HBsAg-, HBcAb+, HBsAb-?
past HBV resolved, need vaccine
134
Extrahepatic manifestations of HBV?
- PAN - MGN - HCC
135
Treatment of HBV?
Entacavir or Tenofovir if: - cirrhotic - INR >1.5 and Br >3 (acute) - chronic with extrahepatics
136
Superinfection with HDV?
chronic HBV is then infected with HDV on top
137
Coinfection of HBV and HDV?
most will clear HBV and then HDV will resolve
138
Acute HCV?
flu like symptoms with mildly elevated ALT
139
Chronic HCV?
- persistent 6 months | - low albumin, elevated INR, hyperBr, thrombocytopenia means advanced cirrhosis or HCC
140
Pregnant woman from another country presents with liver issues and dies. Diagnosis?
HEV
141
Micronodular cirrhosis?
alcoholic hepatitis
142
AST:ALT elevated 2:1, elevated GGT, and elevated MCV. Diagnosis?
Acute alcoholic hepatitis | -treat by abstaining from alcohol
143
Inflammation, fibrosis, and steatosis with no history of alcohol. Diagnosis?
NASH | -treat with aerobic exercise and bariatric surgery
144
Patient with elevated liver enzymes, what should you always ask?
new medications, OTC, herbal supplements
145
Most common cause of acute liver failure in US? Treatment?
acetaminophen - safe 1-4mg/day - treat with N-acetylcysteine
146
Type 1 autoimmune hepatitis antibodies? Treatment?
ANA ASMA anti-F actin - must biopsy - treat with immunosuppression
147
95% of portal HTN caused by?
intrahepatic (cirrhosis)
148
Causes of ascites?
- cirrhosis (75%) - Neoplasms (10%) - CHF (5%) - hypoalbumin
149
Tests performed on ascites?
paracentesis - high albumin gradient > 1.1mg (cirrhosis) - low gradient (nephrotic) - ANC >250 (bacterial peritonitis)
150
Treatment of cirrhotic ascites?
- abstain from alcohol and salt - moderate ascites- use diuretic - refractory- remove fluid and consider TIPS or liver transplant
151
Spontaneous bacterial peritonitis? Pathophys? Organism? Treatment?
complication of ascites - infection of ascitic fluid without intraabdominal source - bacteria traverse into LN - E. Coli most common - ANC >250 - Treat with 3rd gen Cephalosporin
152
Treatment of varices?
1. IVF and blood with clotting factors 2. Octreotide - somatostatin splanchnic vasoconstrictor 3. Control bleeding with Endoscopy 4. Liver transplant
153
Patient with low BP, bounding pulses, jaundice, clubbing, palmar erythema, spider nevi, edema, and ascites. Diagnosis?
Hepatorenal syndrome
154
How to diagnose hepatorenal syndrome?
- low GFR (need diuretic withdrawal) - urine Na <10mmol - Urine osmolality > plasma
155
Type 1 hepatorenal?
- double creatinine - >221umol/L - GFR <20cc/min - hypotension - death in 8-10 weeks - treat with vasoconstrictors, dialysis, and fluids
156
TIPS treatment?
- reduces portal pressure - connects portal vein to hepatic veins - suppresses RAAS
157
Definitive treatment for hepatorenal?
- liver transplant | - limited benefit in type 1 because they die before operation
158
Patient with cirrhosis, asterixis, and mental status change. Diagnosis? Pathophys? Treatment?
Hepatic encephalopathy - necessary to diagnose fulminant hepatitis - increased ammonia and gut toxins get to brain due to lack of liver breakdown - usually a precipitating cause like electrolyte imbalance, GI bleed, Drugs, infection, diet - treat by lactulose which increases gut H+ that binds NH3 - Neomycin, Metronidazole, Rifaximin
159
Why osteoporosis in cirrhosis?
- malabsorption of Vit D - decreased calcium ingestion - bone resorption > formation -screen with DEXA
160
What is the first indication of Portal HTN?
Splenomegaly | -TTP, Leukopenia, recurrent infections
161
Why does coagulopathy occur in cirrhosis?
decreased synthesis of clotting factors - Vit K dependent (2, 7, 9, 10) - treat with IV Vit K Impaired clearance of anticoagulants TTP from splenomegaly

Upper GI (5 decks)

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