Clinical Flashcards
(108 cards)
1
Q
Ddx of N/V?
A
- acute infections
- acute abdominal emergencies
- drugs and toxins
- intracranial disease
- pregnancy
- psychogenic
- gastric retention
- metabolic and endocrine disorders
- chronic indigestion
- labyrinthine disorders
- GI bleed
- cardiac disease
- pain
2
Q
8 attributes of symptoms?
A
- Onset
- Location
- Duration
- Character
- Alleviating/aggravating factors
- Radiation
- Timing
- Severity
OLD CARTS
3
Q
T/F
In order to diagnose IBS, patient needs colonoscopy.
A
False
4
Q
Rome diagnostic criteria for IBS?
A
Recurrent abdominal pain at least 1 day per week in the last 3 months with 2 of the following
- related to defecation
- change in stool frequency
- change in stool form
5
Q
Most commonly diagnosed GI condition?
A
IBS (women more often)
6
Q
Fast transit through intestine produces what type of stool?
A
watery
7
Q
10-30% of patients after acute diarrheal illness get _____.
A
IBS
- increased serotonin
- antiobiotics
- bile acid reabsorption
8
Q
Bacterial growth in IBS?
A
overgrowth of normal flora in SI
9
Q
Psychosocial dysfunction in IBS?
A
- history of abuse
- overactivity of CRF
10
Q
Is colonoscopy, sigmoidoscopy, or TFT recommended for IBS?
A
No
11
Q
Most important component of treatment for IBS?
A
Establish strong relationship with them
-chronic condition, no cure
12
Q
Diarrhea predominant IBS-D treatment?
A
Antispasmodic
Peppermint oil, Hyoscyamine, Dicyclomine
- SM relaxant, anticholinergic
- helps bloating
Antidiarrheal
-does nothing for bloating, cramping
5HT-3 antagonists (Alosetron)
- may improve abdominal pain
- modulate visceral afferent
Rifaximin
-inhibits bacterial DNA dependent RNA pol to inhibit RNA synthesis
Eluxadoline
- give to patient without GB
- works on opioid receptors
- reduces abdominal pain and diarrhea
- increased risk of pancreatitis
Antidepressants
- relief of pain and global symptoms
- TCA are better than SSRI
Antibiotics
-improves bloating by suppressing gut bacteria
13
Q
Treatment of IBS-C?
A
5-HT4 Agonists (Tegaserod)
-increases colonic motility
Chloride Channel activator (Amitiza)
-Cl into lumen to increase fluid and motility
Guanylate cyclase agonists
Osmotic laxatives
Probiotics (lactobacilli)
Fiber
14
Q
IBS-C?
A
More hard and lumpy stools
-can have loose watery stools (<25%)
15
Q
IBS-D?
A
More loose watery stools
-can have hard lumpy stools (<25%)
16
Q
Celiac genetic predisposition?
A
HLA-DQ2 and HLA-DQ8
-useful for ruling out celiac, if patients lack these alleles then they don’t have celiac
17
Q
Celiac antibodies?
A
- Gliadin
- Endomysium (SM CT)
- Tissue tranglutaminase (endomysium)
- Deaminated gliadin peptide
18
Q
Pathophys of celiac?
A
- Tissue transglutaminase released by inflammatory cells in response to inflammation crosslinks gluten proteins and deaminates glutamine to glutamic acid that binds HLA-DQ2/8 and stimulates T cells
- Innate response to wheat proteins
- Increased number of intraepithelial lymphocytes
- Blunting of villi and impaired absorption
19
Q
Patient with foul smelling diarrhea, steatorrhea, flatulence, brain fog, and peripheral neuropathy? Other manifestations or conditions?
A
Celiac
- neuropathy doesnt always improve with gluten free diet, depends on antibodies
- hyposplenism
- iron deficiency
- IgA kidney deposition
- osteomalacia
- malignancy
- dermatitis herpetiformis
- DM
- selective IgA deficiency
- down syndrome
- autoimmune thyroid disease (hypo)
- GERD
- Liver disease (abnormal transaminases in 27% of newly diagnosed)
- pancreatitis
- cirrhosis
- atrophic glossitis
- IBD (UC: pan colitis)
- microscopic colitis (lymphocytic and collagenous)
- Menstrual issues
- Cardiac disease
20
Q
Gold standard of celiac diagnosis?
A
+serology and villous abnormalities
21
Q
Who should be tested for celiac?
A
Person with GI symptoms, extra intestinal symptoms (dermatitis), autoimmune history, and family history (1st degree)
22
Q
Celiac serology?
A
- Anti-tissue transglutaminase Ab
- sensitive and specific
- tTG-IgA is cheaper test and single preferred - Anti-endomysial Ab
- expensive, need expert - Anti-Gliadin Ab
- not used - Synthetic deamidated gliadin peptide
- DGP-IGG sensitive and specific - HLA-DQ2 and DQ8
23
Q
- If positive serology, then what?
2. If negative?
A
- small bowel biopsy
2. maybe false positive, already on gluten free diet, do biopsy still
24
Q
Celiac biopsy?
A
- atrophic mucosa
- flattening of SI folds
- fissures
- nodular mucosa
- scalloping of mucosa
- absence of villi
- increased intraepithelial lymphocytes
- crypt hyperplasia
- blunted villi
- obtain biopsy if found incidentally
25
Other causes of celiac type histo findings?
- Tropical sprue
- Olmesartan enteropathy (medication)
- Crohns
- H. pylori
- HIV enteropathy
- NSAIDS
26
+serology and Marsh 2/3?
established celiac diagnosis
27
+serology and Marsh 0/1?
check HLA-DQ2/8
- if absent, celiac excluded
- if present, put on high gluten challenge test and repeat biopsy 6-12 weeks
28
Negative serology and abnormal biopsy celiac?
check HLA-DQ2/8
- if present, gluten free diet for 1-2 years
- repeat biopsy shows histo response then it is celiac
29
Cause of non-responders celiac?
- poor dietary compliance
- inadvertent ingestion
- other malabsorptive disorder
30
Complication of refractory sprue?
enteropathy associated T cell lymphoma
| -ulcerative jejunitis on endoscopy
31
Who gets tropical sprue?
indigenous populations or someone who lived in the tropics for an extended period of time (mission trip)
-not seen in vacationers
32
Morbid obesity?
- Multifactorial
| - affects every system in body
33
Number one cause of cirrhosis?
obesity
34
Calculating BMI?
weight (kg)/Height(m)^2
35
Class 2 obesity importance?
in order to get surgery, the patient needs another condition other than just obesity
BMI= 35-40
36
3 things insurance companies require before bariatric surgery?
1. See a Nutritionist 3-6 months
- some require patient to lose weight
2. Pulmonary evaluation
- sleep study and CXR
3. Psychosocial evaluation
- do they have social support?
37
Mechanism of restriction weight loss surgery?
- limit caloric intake by reducing stomach size
- LAGB (banding)
- Sleeve gastrectomy
- VBG
38
Mechanism of malabsorption weight loss surgery?
- decrease absorption by shortening length of SI
- metabolic complications arise (protein malnutrition)
- jejuonoileal bypass (not done anymore)
- bipancreatic diversion
39
Gold standard gastric bypass procedure?
Roux en Y gastric bypass
40
Sleeve gastrectomy? Complications?
- laparascopic (restrictive)
- cut off greater curvature
- most common surgery
- 60% weight loss
Complications:
- gastric leak (bleeding)
- heartburn and reflux
- B12 deficiency
41
Roux en y gastric bypass? Complications?
- (laparascopic) restrictive and malabsorptive
- staple the stomach leaving small portion
- anastomose further down SI so biliary juices are used
Complications:
- gastric leak
- ulcers (smokers)
- internal hernia
- dumping syndrome
- B12 deficiency
Better resolution of medical problems (70% weight loss)
42
Which group of people should get the gastric bypass rather than the sleeve?
BMI >55 and Diabetics
43
Biliopancreatic diversion with duodenal switch?
-laparascopic
- best resolution of medical problems (80%)
- wont form ulcers like roux en y (good surgery for smokers)
Complications
- leak
- bowel obstruction
- dumping syndrome
- B12 deficiency
44
Key difference between Roux en y and BPD-DS?
BPD-DS keeps pylorus intact and decreases ulcers
45
Intragastric balloon?
- restrictive
- inflated balloon induces feeling of satiety
- approved for BMI 30-35
- out of pocket cost, not insurance covered
46
Vagal block?
- implanted device to stimulate vagal nerve into indicate satiety
- approved for BMI 35-45
47
Sleeve gastrectomy leaks?
- inadequate blood supply causes leaks, impedes healing
- high intragastric pressure
- abscesses form
- control sepsis with IVF and Abx
48
Roux en y ulcers?
Marginal ulcers
- near gastrojejuonsotomy
- NSAIDS and smokers
- bleed, perforate, obstruct
49
Essential for success for gastric bypass?
- motivation
- change eating behavior
- knowledge of nutrition
- exercise
- support
50
Progression of diverticular disease?
1. Diverticulosis
- outpouching or herniations of sigmoid most common
2. Diverticulitis
- inflammation of diverticulosis
3. Complicated Diverticulitis
- abscess
- infection of cavity
51
Where do diverticuli most often occur?
- areas of colon muscle layer where arteriole penetrates entire wall
- sigmoid colon most common
52
People most at risk of diverticuli?
- intraluminal pressure (constipation, construction workers)
| - elderly
53
How do diverticuli become inflamed?
- fecal material become trapped in pouches
| - attracts inflammatory cells causing swelling
54
One of the top causes of lower GI bleed?
Diverticulosis
55
Person with history of Diverticulosis gets LLQ pain and bleeding has stopped?
Diverticulitis
| -inflammation compresses on the vessels and the bleeding stops
56
Patient with painless lower GI bleed?
Diverticulosis
57
Key history of Diverticulosis?
1. Age >40 (elderly)
2. Low fiber diet increases pressure
3. Obesity
4. Constipation
58
Diagnostics of Diverticulosis?
- No labs
- No imaging (can see on CT with barium)
- Colonoscopy (see holes in colon)
- Hemoccult to detect blood in stool
59
Presentation of Diverticulitis?
1. LLQ crampy pain
2. Constipation or diarrhea
3. Bloating and flatulence
4. N/V (complicated)
5. General abdominal pain (complicated)
60
Key H/P of diverticulitis? If complicated?
1. History of diverticulosis or bleeding
2. LLQ pain
3. Fever
If complicated:
1. tender palpable mass
2. rebound tenderness or guarding
3. Tympany
4. Decreased or absent bowel sounds
-elderly patients on steroids will have few complaints or pain
61
Diagnostics for Diverticulitis?
1. Labs
- CBC (increase in neutrophils) +/- leukocytosis
- Blood culture in complicated
- Hemoccult (can be negative and then become positive if complicated)
2. Imaging
- CT showing pericolic fat stranding, diverticuli, bowel wall thickening
- if complicated: masses, abscesses, peritonitis, fistulas
3. Endoscopy
- NOT during acute event!
- do after inflammation subsides to evaluate number of diverticuli and rule out malignancy
62
Know CT scans for diverticular disease on PPT
*****
63
Management of Diverticulosis?
1. High fiber, low fat diet
| 2. Physical activity
64
Management of Diverticulitis?
1. Outpatient therapy
2. Clear liquid diet for 2-3 days and then advance diet
3. Ciprofloxacin and Metronidazole
65
Management of Diverticulitis?
1. Admission to hospital
2. Bowel rest (NPO) with IVF until fever, pain, and leukocytosis resolves
3. Ciprofloxacin and Metronidazole
4. Drain large abscesses, maybe colectomy if severe complications or perforations
66
Lynch syndrome mutation?
MMR mutation
67
FAP risk of colon cancer?
100%
| -need colectomy
68
Adenoma carcinoma sequence?
1. APC
2. KRAS
3. SMD4
4. p53
- takes years to develop (>50)
- left side of colon
69
Symptoms of Colon cancer?
- change in bowel habits (left)
- hematochezia (rectosigmoid)
- iron deficiency anemia (right)
- ab pain (obstruction)
- tenesmus, rectal pain, diminished caliber of stool (rectal)
- bacteremia, endocarditis, fistulas (strep bovis)
70
First thing you do when you suspect colon cancer?
Colonoscopy
71
Tumor marker for colon cancer?
CEA
72
Stages of cancer histology?
1. In mucosa and submucosa
2. Crosses muscular layer
3. LN
4. Metastasis
73
Bad LN prognosis for colon cancer?
less than 12 LN evaluated
74
CRC treatment of stage 1-3?
1. surgery to remove
2. low risk stage 2 (fluorouracil)
high risk (flurouracil, FOLFOX: oxaliplatin)
3. FOLFOX stage 3
- do chemo and then surgery
75
Endometrial + Colon cancer?
Lynch syndrome
76
CRC colonoscopy screening guidelines?
>2 polyps= 5 years
3-10 polyps= 3 years
>10 polyps= polyposis syndrome
Malignant polyp= treat for CRC
Screen if FH
77
Obstructive jaundice, steatorrhea, venous thrombosis, and weight loss?
pancreatic adenocarcinoma
78
Risks of pancreatic ca?
- age
- smoking
- obesity
- DM
- chronic pancreatitis
- BRCA2
- peutz jegher
- lynch
79
How to diagnose pancreatic ca?
- CT
- ERCP
- EUS
- LFTs
- CA 19-9
80
Treatment of pancreatic ca?
- Pancreatoduodenectomy (whipple)
- Fluorouracil
- Gemcitabine
- FOLFIRINOX
81
Risks of HCC?
- HBV
- HCV
- alcohol
- fatty liver
- hemochromatosis
- wilsons
82
HCC treatment?
Transplant
Liver directed: cTACE
Metastatic: Lenvatinib, Sorafenib (TKI)
83
Esophageal and gastric cancer treatment?
chemo and then surgery then chemo
84
Most common esophageal cancer in US?
adenocarcinoma due to GERD
85
Risk of gastric cancer?
- asian
- H pylori
- atrophic gastritis
- hereditary diffuse gastric cancer (CHD1 mutation)
86
Treatment of HER2+ patients?
Trastuzumab
87
Location of UC vs crohns?
UC: only colon, superficial mucosa, starts in rectum and spread proximal
Crohns: full thickness, full GI tract, most common in terminal ileum and right colon
88
IBD race risk?
- whites
| - ashkenazi jews
89
Important cause of IBD?
microbiome imbalance increases inflammatory response
90
Bloody diarrhea, ab cramping, tenesmus, weight loss, and fatigue with superficial ulcers seen on colonoscopy.
UC
91
Transmural inflammation with skip lesions and noncaseating granulomas?
Crohns
92
Nonbloody diarrhea, weight loss, fever, RLQ pain and mass. complication?
Crohns
- abscesses, fistulas, strictures
- cobblestone mucosa
93
Can you cure crohns with surgery?
No
- palliative
- high rate of recurrence
- UC is cured by surgery
94
How to diagnose IBD?
1. Endoscopy
- Gold standard
2. CBC
- anemia (Fe deficiency, B12)
3. elevated CRP, ESR
4. CMP
- low albumin
5. Stool
- WBC, Culture, C diff, ova and parasite
6. Antibody panels
- P-ANCA
7. Fecal calprotectin
- colon inflammation
95
What is the most sensitive test to view small bowel in IBD?****
CT enterography
MR enterography
96
IBD goals of therapy?****
- induce remission of active disease
- maintenance of remission
- maintain/restore nutrition
- avoid surgery
- avoid complications
- quality of life
***all of the above***
97
Evolving therapy in IBD?***
move from one size fits all to smart custom therapy for right patient
98
5-ASA MoA? uses?
works topically to reduce inflammation
- sulfasalazine (old, cheap)
- Mesalamine (bound to carrier to prevent degradation)
- not effective in Crohns
- used for UC
99
What do you give if not responding to 5-ASA in IBD?
Corticosteroids
- do not treat chronically
- goal is to get off steroids***
100
When do you use steroids in IBD?***
only for acute flares, not for remission
101
Immunomodulators for IBD?
6-Mercaptopurine
Azathioprine
Methotrexate
102
Patient with IBD has acute flare, and you put them on steroids. What is your next step?***
get them off steroids to put them on immunomodulator
-3-6 month for full onset of action
103
ADR of immunomodulators?
- BMS
- lymphoma
- pancreatitis
- skin cancer
- hepatic toxicity
104
Abx used in crohns?
Metronidazole
Ciprofloxacin
Rifaximin
105
When to use biologics (anti-TNF) in IBD?
- steroid refractory or dependent
- immunomodulator refractory or intolerant
- fistulas
106
What to check for before starting biologics in IBD?
TB, HBV, and HCV because TNF is important for immune response, do not want to inhibit
107
Problem with JAK inhibitors for IBD?
increased herpes
108
What IBD does surgery cure?
UC
palliative in crohns
-use for strictures
