GASTRO Flashcards

Question

Which of the following pathologic features characterizes Crohn’s disease as opposed to ulcerative colitis? (HPIM 20th ed. C319 P2262-3) a. Limited to mucosa and superficial submucosa b. Rectum is always involved c. Granulomas are characteristic features d. Can present with megacolon or toxic colitis in fulminant disease

Answer 1

The correct answer is: Granulomas are characteristic features

Answer 2

The correct answer is: Disease limited to the colon

Answer 3

The correct answer is: Recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months

Answer 4

The correct answer is: Probiotics

Answer 5

The correct answer is: Abscess

Answer 6

The correct answer is: Urine urea nitrogen

Answer 7

The correct answer is: Piperacillin-tazobactam

Answer 8

The correct answer is: Colonoscopy with biopsies every 1-2 years

Answer 9

The correct answer is: 75/M undergoing percutaneous endoscopic feeding tube placement

Answer 10

The correct answer is: Cholestyramine resin

Answer 11

The correct answer is: Endoscopy

Answer 12

The correct answer is: Statin therapy need not be discontinued for this patient

Answer 13

UPPER GI BLEEDING: ETIOLOGIES Peptic ulcers: account for ~50% of cases Esophageal varies: varies widely but accounts for ~2-40% of cases Mallory-Weiss tears: account for ~2-10% of cases Erosive disease • Erosive gastritis and duodenitis: ~10-15% • Erosive esophagitis (probably from GERD): ~1-10% Less common causes • Neoplasms • Vascular ectasias: hereditary hemorrhagic telangiectasis (Osler-Weber-Rendu) • Dieulafoy’s lesions • Prolapse gastropathy • Fistulas The correct answer is: Peptic ulcers

Answer 14

SMALL-INTESTINAL GI BLEEDING May account for ~5-10% of GIB cases Accounts for ~75% of cases previously-labelled as obscure GIB The correct answer is: Meckel’s diverticulum

Answer 15

PEPTIC ULCER DISEASE The correct answer is: 48/M with a flat pigmented spot on upper endoscopy

Answer 16

PEPTIC ULCER DISEASE: PROTON PUMP INHIBITORS High-dose constant-infusion IV proton pump inhibitors (PPIs) • 80 mg bolus and 8 mg/hr infusion • Benefits o Sustains intragastric pH >6 o Enhances clot stability o Decreases further rebleeding o Decreases mortality in patients with high-risk ulcers: recent studies showed that high-dose intermitted PPIs are non-inferior to constant-infusion PPI in this population The correct answer is: Sustains intragastric pH to less than 6

Answer 17

DYSPEPSIA: ALARM FEATURES * Age >40 y/o with new-onset dyspepsia * Family history of upper GI * GI bleeding * Jaundice * Left supraclavicular lymphadenopathy * Palpable abdominal mass * Persistent vomiting * Progressive dysphagia * Unexplained weight loss NON-INVASIVE DETECTION OF HELICOBACTER PYLORI The correct answer is: Non-invasive testing for H. pylori

Answer 18

``` DYSPEPSIA: ALARM FEATURES • Age >40 y/o with new-onset dyspepsia • Family history of upper GI • GI bleeding • Jaundice • Left supraclavicular lymphadenopathy • Palpable abdominal mass • Persistent vomiting • Progressive dysphagia • Unexplained weight loss ``` The correct answer is: Upper gastrointestinal endoscopy

Answer 19

UPPER GIB: ENDOSCOPIC FINDINGS • Peptic ulcer disease: varies from clean-based ulcers to ulcers with active oozing/squirting of blood • Mallory-Weiss tears: tears, usually on the gastric side of the GEJ • Esophageal/gastric varices: large, swollen vessels which are fragile and may rupture easily • Erosive disease: visualized breaks in mucosa with no major bleeding due to absence of arteries and veins in the mucosa • Gastric vascular antral ectasia: watermelon stomach • Dieulafoy’s lesion: aberrant bleeding vessel in mucosa from a pinpoint mucosal defect The correct answer is: Mucosal tear on the gastric side of the gastroesophageal junction

Answer 20

EROSIVE DISEASE • Common cause of mild UGIB • Endoscopically visualized breaks confined to the mucosa which do not cause major bleeding due to absence of arteries and veins in the mucosa • Most important cause of gastric and duodenal erosions: NSAID use • Other potential causes of gastric erosions o Alcohol intake o H. pylori infection o Stress-related mucosal injury The correct answer is: NSAID use

Answer 21

DIVERTICULAR BLEEDING • Abrupt in onset, usually painless, sometimes massive • Often from right colon • Chronic or occult bleeding is not characteristic! • 80-90% may stop bleeding spontaneously while 15-40% may rebleed • Treatment o Transcatheter arterial embolization by superselective technique stops bleeding in majority of patients (for those with bleeding seen during angiography) o Persistent/refractory bleeding: segmental surgical resection The correct answer is: Abrupt, usually painless, and sometimes massive

Answer 22

GASTROINTESTINAL BLEEDING: INITIAL ASSESSMENT Measurement of HR and BP: best way to initially assess a patient with gastrointestinal bleeding • Clinically significant bleeding --> postural changes in HR/BP, tachycardia, and finally, recumbent hypotension Hemoglobin does not fall immediately (patients bleed whole blood!) • There is proportional reduction in plasma and red cell volumes • Fall may be seen within 72 hours when extravascular fluid enters vascular space to restore volume The correct answer is: Measurement of heart rate and blood pressure

Answer 23

GI BLEEDING: BLOOD TRANSFUSION Transfusion threshold: <7 g/dL • Restrictive transfusion strategy decreases rebleeding and death in acute UGIB compared to a transfusion threshold of 9 g/dL The correct answer is: 7 g/dL

Answer 24

UPPER GI BLEEDING UGIB more common than LGIB Clinical findings • Hematemesis: usually indicates upper GI source • Melena: indicates blood has been present in the GI tract for >14 hours and as long as 3-5 days [more proximal bleeding site, more likely melena will present] • Hematochezia: usually indicates lower GI source (but may also be from brisk UGIB!) • Hyperactive bowel sounds: blood is cathartic • Elevated BUN: indicates volume depletion and also reflects absorption of blood proteins in the small intestine The correct answer is: Hematemesis

Answer 25

The correct answer is: Start intensive IV PPI; advise clear liquids for ~2 days and ward admission for at least 3 days

Answer 26

LOWER GI BLEEDING: INITIAL ASSESSMENT Patients with LGIB and hemodynamic instability should have upper endoscopy to rule out an upper GI source before evaluation of the lower GI tract The correct answer is: Upper GI endoscopy

Answer 27

SMALL INTESTINAL GI BLEEDING Massive bleeding suspected to be from small intestines: angiography • CT angiography or 99mTc-labeled red cell scan prior to angiography if patient’s clinical status permits Repeat upper and lower endoscopy may also be considered as initial evaluation • Second-look procedures often identify a source in ~25% of cases • Push enteroscopy may substitute for standard upper endoscopy Capsule endoscopy: unable to provide full visualization, biopsy or therapeutic interventions, however CT enterography: may be used in patients with possible small bowel narrowing and may follow negative video capsule (higher sensitivity for small-intestinal masses) “Deep” enteroscopy (double-balloon, single-balloon, or spiral endoscopy) • Next test undertaken for clinically important GIB documented or suspected to be from small intestines • Allows biopsy and provision of therapy OBSCURE GI BLEEDING Other tests used in evaluation of obscure GI bleeding • 99mTc-labeled red blood cell scintigraphy • CT angiography • 99mTc-pertechnate scintigraphy (for Meckel’s diverticulum, especially in young patients) If previous and above are non-revealing, intraoperative endoscopy is indicated in patients with severe recurrent or persistent bleeding requiring repeated blood transfusions. The correct answer is: Angiography

Answer 28

GASTRIC ULCERS In contrast to duodenal ulcers (DU), gastric ulcers (GU) can represent a malignancy and should be biopsied upon discovery • Benign GUs usually seen distal to the junction between the antrum and the acid secretory mucosa • Benign Gus are rare in the gastric fundus The correct answer is: A 1 cm ulcer in the gastric fundus

Answer 29

H. PYLORI INFECTION: RISK FACTORS Two factors that predispose to higher colonization rates • Poor socioeconomic status • Less education Other risk factors • Birth or residence in a developing country • Domestic crowding • Unsanitary living conditions • Unclean food or water • Exposure to gastric contents of an infected individual The correct answer is: Race

Answer 30

INFECTIONS CAUSING NON-HP AND NON-NSAID ULCER DISEASE • Cytomegalovirus • Herpes simplex virus • Helicobacter heilmanii OTHER CAUSES OF NON-HP AND NON-NSAID ULCER DISEASE ``` Drug/Toxin • Bisphosphonates • Chemotherapy • Clopidogrel • Crack cocaine • Glucocorticoids (when combined with NSAIDs) • Mycophenolate mofetil • Potassium chloride Miscellaneous Basophilia in myeloproliferative disease Duodenal obstruction Infiltrating disease Ischemia Radiation therapy Eosinophilic infiltration Sarcoidosis Crohn’s disease Idiopathic hypersecretory state ``` The correct answer is: Cytomegalovirus

Answer 31

PUD-RELATED COMPLICATIONS GI bleeding: most common complication Perforation • Penetration: form of perforation in which ulcer bed tunnels into an adjacent organ Gastric outlet obstruction: less common complication • Mechanisms o Relative obstruction from ulcer-related inflammation and edema in the peripyloric region (resolves with ulcer healing) o Fixed mechanical obstruction from scar formation in the peripyloric areas The correct answer is: Gastric outlet obstruction

Answer 32

H. PYLORI TREATMENT Combination of antibiotics and acid suppression No single agent is effective in eradicating the organism Combination therapy for 14 days provides the greatest efficacy • Shorter courses least successful Triple therapy is recommended • Dual therapy has unacceptable eradication rates (<80-85%) • Quadruple therapy usually reserved for treatment failure The correct answer is: Esomeprazole, clarithromycin, and amoxicillin for 14 days

Answer 33

FUNCTIONAL DYSPEPSIA Cause of symptoms of >70% of patients with dyspepsia Bothersome postprandial fullness, early satiety, or epigastric pain or burning with symptom onset at least 6 months before diagnosis in the absence of an organic cause Subclassifications • Postprandial distress syndrome: meal-induced fullness and early satiety • Epigastric pain syndrome: epigastric pain or burning which may or may not be meal-related Most patients follow a benign course but some who also have H. pylori infection or concurrent NSAID use develop ulcers The correct answer is: Functional dyspepsia

Answer 34

GERD: TESTING AND TREATMENT Once these alarm features are excluded, patients with typical GERD do not need further evaluation and are treated empirically • Patients <55 y/o without alarm factors should be managed based on H. pylori prevalence o If low (<10%), 4-week trial of acid suppressants o If high <>10%), test and treat for H. pylori and acid-suppression if failed Alarm features • Odynophagia or dysphagia • Unexplained weight loss • Recurrent vomiting • Occult or gross GI bleeding • Jaundice • Palpable mass or adenopathy • Family history of gastroesophageal malignancy Upper endoscopy: indicated to exclude mucosal injury in patients with atypical symptoms or alarm factors Ambulatory esophageal pH testing: for drug-refractory symptoms and atypical symptoms High-resolution esophageal manometry: when surgical management of GERD is contemplated The correct answer is: Non-invasive H. pylori testing

Answer 35

TESTS TO DETECT H. PYLORI Urea breath test relies on presence of urease secreted by H. pylori to digest the swallowed radioactive urea and liberates 14C or 13C as part of ammonia Urea breath test may be false negative with recent use PPIs, antibiotics, or bismuth compounds Stool antigen testing not useful to establish proof of eradication The correct answer is: Exposure to low-dose radiation is a limitation of the urea breath test

Answer 36

``` GERD: EXTRAESOPHAGEAL SYNDROMES Well-established association with GERD • Chronic cough • Laryngitis • Asthma • Dental erosions GERD as potentially contributory • Pharyngitis • Pulmonary fibrosis • Chronic sinusitis • Cardiac arrhythmias • Sleep apnea • Recurrent aspiration pneumonia Potential mechanisms • Regurgitation with direct contact between refluxate and supraesophageal structures • Vagovagal reflex wherein reflux activation of esophageal afferent nerves triggers efferent vagal reflexes such as bronchospasm, cough, or arrythmias ``` The correct answer is: Dental erosions

Answer 37

APPROACH TO PRIMARY PREVENTION OF NSAID-INDUCED MUCOSAL INJURY Using lowest possible dose of agent for shortest period of time possible Using NSAIDs that are theoretically less injurious • Lower likelihood of GI and CV toxicity: naproxen and ibuprofen Using newer topical NSAID preparations Using concomitant medical therapy to prevent NSAID-induced injury The correct answer is: Using oral over topical NSAIDs preparations

Answer 38

STRESS-RELATED MUCOSAL INJURY Injury most commonly observed in the acid-producing (fundus and body) portions of the stomach Most common presentation: GI bleeding (usually minimal but may be life-threatening) Best choice for prophylaxis: PPIs ``` Treatment of bleeding • Endoscopy • Intraarterial vasopressin • Embolization • Surgery ``` The correct answer is: Proton pump inhibitors

Answer 39

GASTRITIS Should be reserved for histologically documented inflammation of the gastric mucosa NOT the mucosal erythema seen during endoscopy NOT interchangeable with dyspepsia ``` Can be classified based on • Time course (acute vs chronic) • Histologic features • Anatomic distribution • Proposed pathogenic mechanism Acute gastritis • Most common cause: infectious Chronic gastritis • Inflammatory cell infiltrate: lymphocytes and plasma cells with scanty neutrophils • Early phase: superficial gastritis • Next phase: atrophic gastritis • Final phase: gastric atrophy ``` The correct answer is: Infections

Answer 40

CHRONIC GASTRITIS Spectrum: from infiltration of mucosa with lymphocytes and plasma cells to progressive glandular destruction, with atrophy and metaplasia • Intestinal metaplasia: conversion of gastric glands into a small intestinal phenotype with small-bowel mucosal glands containing goblet cells [this is an important predisposing factor for gastric cancer] Type A: body-predominant (autoimmune) Type B: antral-predominant (H. pylori-related) Type AB: mixed antral/body picture The correct answer is: Conversion of gastric glands into a small intestinal phenotype

Answer 41

TYPE A GASTRITIS • Traditionally associated with pernicious anemia --> autoimmune gastritis • Anti-IF antibodies are more specific than parietal cell antibodies for this type of gastritis • Higher incidence of specific familial histocompatibility haplotypes such as HLA-B8 and HLA-DR3 The correct answer is: Anti-intrinsic factor antibodies

Answer 42

GASTRIC MALT LYMPHOMA Low-grade B cell lymphoma associated with H. pylori Chronic T cell stimulation caused by the infection leads to production of cytokines that promote tumor growth Tumor is staged with CT of the abdomen and endoscopic US Tumor growth remains dependent on presence of H. pylori and its eradication is often associated with complete regression of the tumor • Patients are followed by EUS every 2-3 months • If tumor is stable or decreases in size --> no other therapy needed • If tumor grows --> re-biopsy to check for evolution to high-grade lymphoma The correct answer is: Tumor growth is dependent on presence of H. pylori

Answer 43

MENETRIER'S DISEASE Very rare gastropathy characterized by large, tortous mucosal folds most prominent in the body and fundus, sparing the antrum Histology: massive foveolar hyperplasia and marked reduction in oxyntic glands, parietal cells, and chief cells In children, usually related to CMV (etiology in adults unknown) Associated with overstimulation of EGFR pathway • Cetuximab is now considered as the first-line therapy for this disease • Total gastrectomy for severe disease with persistent and substantial protein loss despite use of cetuximab The correct answer is: Menetrier’s disease

Answer 44

INTESTINAL ISCHEMIA Occurs when splanchnic perfusion fails to meet the demands of the intestines --> ischemic tissue injury Risk factors The correct answer is: Mesenteric venous thrombosis

Answer 45

INTESTINAL ISCHEMIA: ANATOMY Areas which are inherently at risk for decreased blood flow • Griffith’s point: splenic flexure • Sudeck’s point: descending/sigmoid colon The correct answer is: Griffith’s point

Answer 46

ARTERIOOCCLUSIVE MESENTERIC ISCHEMIA Severe acute, nonremitting abdominal pain strikingly out of proportion to PE findings • With exception of minimal abdominal distention and hypoactive bowel sounds, early abdominal PE is unimpressive • Later findings: peritonitis, cardiovascular collapse Associated symptoms • Nausea and vomiting • Transient diarrhea • Anorexia • Bloody stools The correct answer is: Arterioocclusive mesenteric ischemia

Answer 47

ARTERIOOCCLUSIVE MESENTERIC ISCHEMIA: EMBOLIC DISEASE Diagnosis: CT angiography; early laparotomy Treatment of underlying cause: anticoagulation, cardioversion, proximal thrombectomy Treatment of specific lesion: laparotomy, embolectomy, vascular bypass, assessment of viability and possible resection of dead bowel ``` Other essential components of treatment • Hydration • Antibiotics • Reversal of acidosis • Oxygenation • Avoidance of vasoconstrictors ``` The correct answer is: Early laparotomy

Answer 48

NON-OCCLUSIVE/VASOSPASTIC MESENTERIC ISCHEMIA Presents with generalized abdominal pain, anorexia, bloody stools and abdominal distention Patients usually obtunded; PE findings not always useful Advanced disease: metabolic acidosis, leukocytosis, elevated amylase or creatinine phosphokinase, and/or lactic acidosis Diagnosis • Vasospasm: angiography • Hypoperfusion: spiral CT or colonoscopy Treatment of underlying cause: hydration, support cardiac output, avoid vasoconstrictors Treatment of specific lesion • Vasospasm: intraarterial vasodilators • Hypoperfusion: delayed laparotomy; assess viability and resect dead bowel Other supportive treatment • Hydration, antibiotics, acidosis reversal, oxygenation, support cardiac output, avoid vasoconstrictors The correct answer is: Nonocclusive mesenteric ischemia

Answer 49

MESENTERIC VENOUS THROMBOSIS Diagnosis: spiral CT; angiography with venous phase Treatment of underlying cause: anticoagulation; massive hydration ``` Treatment of specific lesion: • Anticoagulation +/- laparotomy • Thrombectomy/catheter-directed thrombolysis • Assess viability and resect dead bowel Other supportive therapies • Antibiotics • Reverse acidosis • Optimize oxygenation • Support cardiac output • Avoid vasoconstrictors ``` The correct answer is: Anticoagulation

Answer 50

ACUTE APPENDICITIS: IMAGING Plain abdominal films: rarely helpful; not usually obtained unless other conditions such as intestinal obstruction, perforated viscus or ureterolithiasis need to be ruled out Presence of fecalith is NOT diagnostic Ultrasound: highly operator-dependent; more useful to identify pelvic pathology in women • Suggestive findings: wall thickening, increased appendiceal diameter, presence of free liquid CT scan: high negative predictive value • Superior method for assessing severity of disease • Suggestive findings: dilation >6 mm with wall thickening, lumen that does not fill with enteric contrast, fatty tissue stranding or air surrounding the appendix The correct answer is: CT of the abdomen without contrast

Answer 51

ACUTE APPENDICITIS: TREATMENT Either laparoscopic or open appendectomy is satisfactory for patients with uncomplicated appendicitis Management of patients with phlegmon or abscess • Broad-spectrum antibiotics • Drainage if there is an abscess >3 cm in diameter • Parenteral fluids • Bowel rest • Appendix can be safely removed 6-12 weeks later when inflammation has diminished The correct answer is: Emergent laparoscopic appendectomy

Answer 52

ACUTE PERITONITIS Most often (but not always) infectious in origin Cardinal signs and symptoms • Abdominal pain, typically severe • Abdominal tenderness: often diffuse with local guarding, rigidity and with other signs of parietal peritoneal irritation • Fever Bowel sounds usually absent to hypoactive Most present with tachycardia and signs of volume depletion Labs: leukocytosis; severe acidosis The correct answer is: Hyperactive bowel sounds

Answer 53

``` ACUTE PERITONITIS Most commonly associated with bacterial infection but can be caused by abnormal presence of the following: • Gastric contents • Bile • Pancreatic enzymes • Blood • Urine • Foreign bodies ``` The correct answer is: Gastric contents

Answer 54

DRUG-INDUCED LIVER INJURY: IDIOSYNCRATIC DRUG REACTIONS Occurrence of hepatitis • Usually infrequent (1 in 103-105 patients) • Unpredictable • Response not clearly dose-dependent • May occur any time during or shortly after drug exposure The correct answer is: May occur at any time

Answer 55

The correct answer is: Androgenic steroids

Answer 56

TOXIC/DRUG-INDUCED HEPATIC DISEASE: TREATMENT Treatment largely supportive • Except in paracetamol hepatotoxicity: N-acetylcysteine is effective Fulminant hepatitis: liver transplantation may be life-saving Withdrawal of suspected agent is indicated at first sign of an adverse reaction Agents used occasionally but with questionable value • Glucocorticoids: drug hepatotoxicity with allergic features • Silibinin: hepatotoxic mushroom poisoning • Ursodeoxycholic acid: cholestatic drug hepatotoxicity The correct answer is: Paracetamol

Answer 57

PARACETAMOL HEPATOTOXICITY Most prevalent cause of acute liver failure in the Western world • Fatal fulminant disease usually associated with ingestion of >25 g Blood levels of paracetamol correlated with severity of hepatic injury Clinical manifestations • Early manifestations (4-12 hours post-ingestion): nausea, vomiting, diarrhea, abdominal pain and shock • 24-28 hrs after: early features abate and hepatic injury becomes apparent • 3-5 days post-ingestion: maximal abnormalities and hepatic failure Extremely high aminotransferase levels with low bilirubin levels: characteristic of this hyperacute injury The correct answer is: Extremely elevated aminotransferase levels with low bilirubin levels

Answer 58

ISONIAZID HEPATOTOXICITY Toxic and idiosyncratic reaction ~10% of patients on INH may develop elevations in serum transaminases during first few weeks of therapy • Most are self-limited, mild (ALT <200) and resolve despite continued use (adaptive response which allows continuation of the agent if symptoms and progressive enzyme elevations do not follow initial elevations) Variable latency period up to 6 months • More frequent in alcoholics and patients on other meds (barbiturates, rifampin, pyrazinamide) The correct answer is: Resolution of aminotransferase elevations require discontinuation of the drug

Answer 59

STATIN HEPATOTOXICITY Idiosyncratic mixed hepatocellular and cholestatic reaction ~1-2% of patients taking statins experience asymptomatic, reversible elevation (>3x) of aminotransferase activity Clinically meaningful aminotransferase elevations are rare • Liver test monitoring not necessary • Statins need not be discontinued in patients found to have asymptomatic isolated aminotransferase elevations Statin hepatotoxicity NOT increased in patients with chronic hepatitis C, hepatic steatosis, or other underlying liver diseases • Statins can be used safely in these patients The correct answer is: Statin therapy need not be discontinued for this patient

Answer 60

IRRITABLE BOWEL SYNDROME (IBS) Functional bowel disorder characterized by abdominal pain or discomfort and altered bowel habits in absence of detectable structural abnormalities Malnutrition due to inadequate caloric intake is rare in IBS The correct answer is: Presence of malnutrition

Answer 61

IRRITABLE BOWEL SYNDROME (IBS) Alteration in bowel habits is the most consistent clinical feature in IBS Most common pattern: constipation alternating with diarrhea, usually with one of these symptoms predominating • Bowel pattern subtypes, however, are highly unstable Diarrhea in IBS usually consists of small volumes of loose stools (most have stool volumes <200 mL) • Nocturnal diarrhea DOES NOT occur in IBS • May be aggravated by emotional stress or eating Most experience tenesmus (sense of incomplete evacuation) Bleeding is NOT a feature Malabsorption or weight loss DOES NOT occur The correct answer is: Alteration in bowel habits

Answer 62

IRRITABLE BOWEL SYNDROME (IBS) The correct answer is: Persistent diarrhea after a 48-hour fast

Answer 63

``` IRRITABLE BOWEL SYNDROME (IBS) Factors to consider when determining aggressiveness of diagnostic evaluation • Duration of symptoms • Change of symptoms over time • Age and sex of patient • Referral status of patient • Prior diagnostic studies • Family history of colorectal malignancy • Degree of psychosocial dysfunction ``` The correct answer is: 30/M with 6 months of crampy lower abdominal pain relieved by bowel movements which are usually loose with symptoms worse during daytime at work

Answer 64

IRRITABLE BOWEL SYNDROME (IBS) Laboratory features that argue against IBS • Anemia • Elevated ESR • Presence of leukocytes or blood in stool • Stool volume >200-300 mL/day Alarm symptoms and lab features warrant further investigation to rule out other GI disorders The correct answer is: Endoscopy

Answer 65

IRRITABLE BOWEL SYNDROME (IBS) Meticulous dietary history may reveal substances (e.g., coffee, disaccharides, legumes, and cabbage) that aggravate symptoms • Excessive fructose and artificial sweeteners may cause diarrhea, bloating, cramping, or flatulence Advice against nutritionally depleted diets Diets low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) has been shown to be helpful in IBS patients The correct answer is: Fermentable oligosaccharides, disaccharides, monosaccharides and polyols

Answer 66

IRRITABLE BOWEL SYNDROME: TREATMENT Treatment depends on severity of disorders and predominant symptoms The correct answer is: Cholestyramine resin

Answer 67

The correct answer is: 75/M undergoing percutaneous endoscopic feeding tube placement

Answer 68

The correct answer is: Colonoscopy with biopsies every 1-2 years

Answer 69

COLONIC PSEUDO-OBSTRUCTION Ogilvie’s syndrome Relatively rare disease May be seen among elderly patients after nonabdominal surgery or in patients with underlying autonomic dysfunction Treatment: neostigmine • Acetylcholinesterase inhibitor that increase parasympathetic activity and stimulate colonic motility • Initiated once it is certain that there is no mechanical obstruction • Surgery may be needed in bowel perforation or impending perforation The correct answer is: Colonic pseudo-obstruction

Answer 70

FUNCTIONAL OBSTRUCTION Also known as ileus and pseudo-obstruction Present when dysmotility prevents intestinal contents from being propelled distally No mechanical blockage exists Most common form: ileus after intraabdominal surgery • Most often transient but prolongs hospital stay Treatment: supportive with IV fluids and NGT decompression • Pharmacologic therapy is NOT yet proven to be efficacious or cost-effective • Peripherally active mu-opioid receptor antagonists (e.g., alvimopan and methylnatrexone) may accelerate gastrointestinal recovery in some post-abdominal surgery patients The correct answers are: Hypernatremia, Hyperglycemia

Answer 71

DIVERTICULAR DISEASE Two types (intestinal) • True: saclike herniation of entire bowel wall • False (pseudo-diverticula): involves only a protrusion of the mucosa and submucosa through the muscularis propria of the colon (most commonly affects colon) These occur at points where the nutrient artery, or vasa recti, penetrates through the muscularis propria, resulting in a break in the integrity of the colonic wall • Vasa recti either compressed or eroded --> perforation or bleeding Dysbiosis also an important aspect of this disease Commonly affects left and sigmoid colon; rectum is always spared Diverticulitis: inflammation of a diverticulum The correct answer is: Rectum

Answer 72

DIVERTICULITIS: IMAGING Diagnosis best made on CT with ff findings: • Sigmoid diverticula • Thickened colonic wall >4 mm • Inflammation with the pericolic • Collection of contrast material or fluid Air-fluid levels in LLQ may rarely be seen: signifies giant diverticulum Colonoscopy should be performed ~6 weeks after an attack of diverticular disease to exclude colorectal disease The correct answer is: Collection of contrast or material or fluid may be seen in the pathologic lesion

Answer 73

COMPLICATED DIVERTICULAR DISEASE Diverticular disease associated with an abscess or perforation, or less common with a fistula Perforated diverticular disease staged using the Hinchey classification system The correct answer is: Stage II

Answer 74

DIVERTICULAR DISEASE: MEDICAL MANAGEMENT Asymptomatic diverticular disease (discovered during imaging/colonoscopy): lifestyle changes (high fiber diet and smoking cessation) Symptomatic uncomplicated diverticular disease • Bowel rest • Hospitalization for those unable to take oral therapy • Antimicrobial coverage: 3rd-generation cephalosporin or ciprofloxacin and metronidazole (addition of ampicillin for non-responders) • Limited diet until pain resolves The correct answer is: Initiation of a fiber-enriched diet and smoking cessation

Answer 75

HEMORRHOIDAL DISEASE Treatment for bleeding hemorrhoids is based on the stage of disease Young patients with no family history of colorectal CA: treat first and do colonoscopy if bleeding continues Older patients who have not had colorectal cancer screening: colonoscopy or flexible sigmoidoscopy The correct answer is: Operative hemorrhoidectomy

Answer 76

ANAL FISSURE Occurs in all ages but are more common in 3rd to 5th decades Associated with constipation, diarrhea, infectious etiologies, perianal trauma and Crohn’s disease A fissure that is not in the posterior or anterior position should raise suspicion for other causes (e.g., TB, syphilis, Crohn’s disease, and malignancy) Chronic fissure: indicated by presence of hypertrophied anal papilla at the proximal end of the fissure and a sentinel pile or skin tag at the distal end Anal manometry: elevated anal resting pressures; sawtooth deformity with paradoxical contractions of the sphincter muscles (pathognomonic) The correct answer is: Fissure in the lateral position

Answer 77

INFLAMMATORY BOWEL DISEASE: EPIDEMIOLOGY Greatest incidence: white and Jewish people (incidence in Hispanic in Asian people is increasing, however) Peak incidence in 2nd to 4th decades (with second modest rise between the 7th and 9th decades) The correct answer is: Smoking may prevent disease

Answer 78

INFLAMMATORY BOWEL DISEASE: CROHN'S DISEASE Discontinuous lesions with presence of strictures and fissures Hallmark of Crohn’s Disease: granulomas throughout bowel wall and may involve lymph nodes, mesentery, peritoneum, liver and pancreas The correct answer is: Non-caseating granuloma throughout the bowel wall

Answer 79

``` IBD: PROBIOTICS Probiotics may prevent recurrence of pouchitis in IBD • Lactobacillus • Bifidobacterium • Streptococcus salivarius ``` The correct answer is: Bifidobacterium spp.

Answer 80

IBD AND CANCER Cancer risks in CD and UC are probably equivalent for similar extent and duration of disease • Same endoscopic surveillance strategy for both CD and UC • Annual or biennial colonoscopy with multiple biopsies is recommended for patients with >8-10 years of extensive colitis (>1/3 of colon involved) or 12-15 years of proctosigmoiditis Risk factors for cancer • UC: long-duration disease, extensive disease, family hx of colon CA, PSC, colon stricture, presence of post-inflammatory pseudopolyps • CD: long-duration disease, extensive disease, bypassed colon segments, colon strictures, PSC, family history of colon cancer Other cancers • CD: may have increased risk of NHL, leukemia, and MDS; CA in lower rectum and anal canal (SCCA) • Low absolute risk of small-bowel adenoCA The correct answer is: Small-bowel adenocarcinoma risk is significantly increased in CD

Answer 81

CLOSTRIDIUM DIFFICILE INFECTION (CDI) Acquired most commonly in association with antimicrobial use and consequent disruption of the normal colonic microbiota Most commonly diagnosed diarrheal illness in the hospital Results from ingestion of spores of C. difficile that vegetate, multiply, and secrete toxics causing diarrhea and pseudomembranous colitis is most severe cases Antibiotic association • Clindamycin, ampicillin, cephalosporins: first antibiotics associated with CDI • Frequently responsible: 2nd- and 3rd-generation cephalosporins • Most recent implicated drug class: fluoroquinolones • Penicillin/beta-lactamase combinations pose significantly less risk • However, all antibiotics, including vancomycin and metronidazole have been found to carry a risk of subsequent CDI The correct answer is: Piperacillin-tazobactam

Answer 82

CDI: DIAGNOSIS Diagnosis of CDI is based on a combination of clinical criteria * Diarrhea (>3 unformed stools per 24 hours for >2 days) with no other recognized cause plus * Detection of toxin A or B in the stool, detection of toxin-producing C. difficile in the stool by NAAT/PCR or by culture or * Visualization of pseudomembranes in the colon (advanced finding) The correct answer is: 72/F with two LBM per day for the past 3 days with no fever and normal WBCs; took amoxicillin for throat itchiness 1 day prior to presentation

Answer 83

FOOD POISONING History and stool examination indicating a non-inflammatory etiology of diarrhea and there is an evidence of a common-source outbreak --> ingestion of specific foods and time of onset of symptoms can provide clues to bacterial cause of illness Not all food poisoning has a bacterial cause • Capsaicin: short-incubation period • Toxins from fish and shellfish The correct answer is: Staphylococcus aureus

Answer 84

MRCP is superior to ultrasound and CT for detecting choledocholithiasis MRCP is useful in the diagnosis of bile duct obstruction and congenital biliary abnormalities ERCP is more valuable in evaluating ampullary lesions and primary sclerosis cholangitis Ultrasound and MRI are used to assess hepatic vasculature and hemodynamics and to monitor surgically or radiologically placed vascular shunts including TIPS. Multi-detector or spiral CT and MRI with contrast enhancement for evaluation of hepatic masses, staging of liver tumors, and pre-operative assessment US and MR Elastography: hepatic stiffness - fibrosis and cirrhosis except when in activity Liver biopsy: gold standard for chronic liver disease; more often useful for assessment of the severity (grade) and stage of liver dam- age, prediction of prognosis, and monitoring of the response to treatment. Liver biopsy is also the most accurate means of assessing stage of disease as early or advanced, precirrhotic, and cirrhotic. The correct answer is: Ultrasound is used to to monitor surgically or radiologically placed vascular shunts

Answer 85

AMINOTRANSFERASES ALT • found primarily in the liver • liver cell necrosis is not required for the release of aminotransferases • There is a poor correlation between the degree of liver cell damage and the level of aminotransferases • Aminotransferases has no prognostic significance in acute hepatocellular disorders ``` Elevations in ALT: • >300 non-specific • >1000 IU/L o viral hepatitis o ischemic liver injury o toxin or drug induced liver injury o choledocholithiasis ALT> AST: acute hepatocellular disorder AST ALT ratio < 1 chronic viral hepatitis and non-alcoholic fatty liver disease AST: ALT 2-3:1 alcoholic liver disease Normal ALT in alcoholic liver disease deficiency of pyridoxal phosphate while AST in alcoholic liver disease is rarely > 300 ``` The correct answer is: ALT of > 1000 IU may suggest acute phase of choledocholithiasis

Answer 86

ENZYMES THAT REFLECT CHOLESTASIS The activities of three enzymes— alkaline phosphatase, 5'-nucleotidase, and g-glutamyl transpeptidase (GGT)—are usually elevated in cholestasis. Alkaline phosphatase and 5'-nucleotidase are found in or near the bile canalicular membrane of hepatocytes, whereas GGT is located in the endoplasmic reticulum and in bile duct epithelial cells. Reflecting its more diffuse localization in the liver, GGT elevation in serum is less specific for cholestasis than are elevations of alkaline phosphatase or 5'-nucleotidase. Some have advocated the use of GGT to identify patients with occult alcohol use. Its lack of specificity makes its use in this setting questionable. The normal serum alkaline phosphatase consists of many distinct isoenzymes found in the liver, bone, placenta, and, less commonly, in the small intestine. Patients over age 60 can have a mildly elevated alkaline phosphatase (1–1.5 times normal), whereas individuals with blood types O and B can have an elevation of the serum alkaline phosphatase after eating a fatty meal due to the influx of intestinal alkaline phosphatase into the blood. It is also elevated in children and adolescents undergoing rapid bone growth because of bone alkaline phosphatase, and late in normal pregnancies due to the influx of placental alkaline phosphatase. If an elevated serum alkaline phosphatase is the only abnormal finding in an apparently healthy person, or if the degree of elevation is higher than expected in the clinical setting, identification of the source of elevated isoenzymes is helpful. This problem can be approached in two ways. First, and most precise, is the fractionation of the alkaline phosphatase by electrophoresis. The second, best substantiated, and most available approach involves the measurement of serum 5¢-nucleotidase or GGT. These enzymes are rarely elevated in conditions other than liver disease. In the absence of jaundice or elevated aminotransferases, an elevated alkaline phosphatase of liver origin often, but not always, suggests early cholestasis and, less often, hepatic infiltration by tumor or granulomata. Other conditions that cause isolated elevations of the alkaline phosphatase include Hodgkin’s disease, diabetes, hyperthyroidism, congestive heart failure, amyloidosis, and inflammatory bowel disease. The level of serum alkaline phosphatase elevation is not helpful in distinguishing between intrahepatic and extrahepatic cholestasis. There is essentially no difference among the values found in obstructive jaundice due to cancer, common duct stone, sclerosing cholangitis, or bile duct stricture. Values are similarly increased in patients with intrahepatic cholestasis due to drug-induced hepatitis, primary biliary cirrhosis, rejection of transplanted livers, and, rarely, alcohol-induced steatohepatitis. Values are also greatly elevated in hepatobiliary disorders seen in patients with AIDS (e.g., AIDS cholangiopathy due to cytomegalovirus or cryptosporidial infection and tuberculosis with hepatic involvement). The correct answer is: (+) 5’-nucleotidase in an isolated alkaline phosphatase elevation

Answer 87

The correct answer is: ERCP for further determination of biliary duct dilatation

Answer 88

EVALUATING ACUTE HEPATITIS HBsAg, IgM anti-HAV, IgM anti-HBc, and anti-HCV IgM anti-HBc, IgG Anti-HAV, with or without IgM anti-HBc, represents HBV infection If IgM anti-HBc is present, the HBV infection is considered acute; IgM anti-HBc is absent, the HBV infection is considered chronic. A diagnosis of acute hepatitis B can be made in the absence of HBsAg when IgM anti-HBc is detectable. A diagnosis of acute hepatitis A is based on the presence of IgM anti-HAV. If IgM anti-HAV coexists with HBsAg, a diagnosis of simultaneous HAV and HBV infections can be made; if IgM anti-HBc (with or without HBsAg) is detectable, the patient has simultaneous acute hepatitis A and B,and if IgM anti-HBc is undetectable, the patient has acute hepatitis. A superimposed on chronic HBV infection. The presence of anti-HCV supports a diagnosis of acute hepatitis C. Occasionally, testing for HCV RNA or repeat anti-HCV testing later during the illness is necessary to establish the diagnosis. Absence of all serologic markers is consistent with a diagnosis of “non-A, non-B, non-C” hepatitis (no other proven human hepatitis viruses have been identified), if the epidemiologic setting is appropriate. The correct answer is: HBsAg, IgM anti-HAV, IgM anti-HBc, and anti-HCV

Answer 89

EVALUATING CHRONIC HEPATITIS In patients with chronic hepatitis, initial testing should consist of HBsAg and anti-HCV. Anti-HCV supports and HCV RNA testing establishes the diagnosis of chronic hepatitis C. If a serologic diagnosis of chronic hepatitis B is made, testing for HBeAg and anti-HBe is indicated to evaluate relative infectivity. Testing for HBV DNA in such patients provides a more quantitative and sensitive measure of the level of virus replication, and therefore is very helpful during antiviral therapy. In patients with chronic hepatitis B and normal aminotransferase activity in the absence of HBeAg, serial testing over time is often required to distinguish between inactive carriage and HBeAg-negative chronic hepatitis B with fluctuating virologic and necroinflammatory activity. In persons with hepatitis B, testing for anti-HDV is useful in those with severe and fulminant disease, with severe chronic disease, with chronic hepatitis B and acute hepatitis-like exacerbations, with frequent percutaneous exposures, and from areas where HDV infection is endemic. The correct answer is: HBsAg and Anti-HCV

Answer 90

The correct answer is: HBeAg appears concurrently with or shortly after HBsAg

Answer 91

The correct answer is: Had recovered from Hepatitis B

Answer 92

The correct answer is: (+)HBsAg, (-) Anti-HBsAg, ( + ) Anti-HBc, (-) HBeAg, (+) Anti-HBe

Answer 93

INFECTIVITY OF HEPATITIS B Chronic HBV infection can occur in the presence or absence of serum hepatitis B e antigen (HBeAg), and generally, for both HBeAg-reactive and HBeAg-negative chronic hepatitis B, the level of HBV DNA correlates with the level of liver injury and risk of progression. In HBeAg-reactive chronic hepatitis B, the relatively replicative phase is characterized by the presence in the serum of HBeAg and HBV DNA levels well in excess of 103−104 IU/mL, sometimes exceeding 109 IU/mL; by the presence in the liver of detectable intrahepatocyte nucleocapsid antigens (primarily hepa- titis B core antigen [HBcAg]); by high infectivity; and by accompanying liver injury. Patients in the replicative phase tend to have more severe chronic hepatitis. In HBeAg-reactive chronic hepatitis B, the relatively nonreplicative phase is characterized by the absence of the conventional serum marker of HBV replication (HBeAg), the appearance of anti-HBe, levels of HBV DNA below a threshold of ~103 IU/mL, the absence of intrahepatocytic HBcAg, limited infectivity, and minimal liver injury. Those in the nonreplicative phase tend to have minimal or mild chronic hepatitis or to be inactive hepatitis B carriers. The likelihood in a patient with HBeAg-reactive chronic hepatitis B of converting spontaneously from relatively replicative to nonreplicative infection is approximately 10% per year HBeAg-negative chronic hepatitis B (i.e., chronic HBV infection with active virus replication, readily detectable HBV DNA but without HBeAg [anti-HBe-reactive]), have levels of HBV DNA that are several orders of magnitude lower (no more than 105−106 IU/mL) than those observed in the HBeAg-reactive subset, HBeAg- negative chronic hepatitis B can have progressive liver injury (complicated by cirrhosis and HCC) and experience episodic reactivation of liver disease reflected in fluctuating levels of aminotransferase activity (“flares”). The biochemical and histologic activity of HBeAg-negative disease tends to correlate closely with levels of HBV replication, unlike the case mentioned above of Asian patients with HBeAg-reactive chronic hepatitis B during the early decades of their HBV infection. The correct answer is: the appearance of anti-HBe

Answer 94

The correct answer is: Sustains intragastric pH to less than 6

Answer 95

The correct answer is: Gastric contents

Answer 96

The correct answer is: Androgenic steroids

Answer 97

The correct answer is: Extremely elevated aminotransferase levels with low bilirubin levels

Answer 98

The correct answer is: Alteration in bowel habits

Answer 99

The correct answer is: 30/M with 6 months of crampy lower abdominal pain relieved by bowel movements which are usually loose with symptoms worse during daytime at work

Answer 100

The correct answer is: fruit juices in cans or carton packs

Answer 101

The correct answer is: Crohn’s disease

Answer 102

The correct answer is: Associated with vomiting

Answer 103

The correct answer is: Upper endoscopy

Answer 104

The correct answer is: 1.0 ulcer in the gastric fundus

Answer 105

The correct answer is: Cytomegalovirus

Answer 106

The correct answer is: Clopidogrel

Answer 107

The correct answer is: Omeprazole, bismuth subcitrate, tetracycline, and metronidazole for 14 days

Answer 108

The correct answer is: False negative

Answer 109

The correct answer is: Laryngitis

Answer 110

The correct answer is: Proton pump inhibitors

Answer 111

The correct answer is: Infections

Answer 112

The correct answer is: Conversion of gastric glands into a small intestinal phenotype

Answer 113

The correct answer is: diffuse tenderness with local guarding

Answer 114

The correct answer is: Arterial embolus

Answer 115

The correct answer is: Abdominal CT scan has high negative predictive value

Answer 116

The correct answer is: Ultrasound is used to to monitor surgically or radiologically placed vascular shunts

Answer 117

The correct answer is: AST: ALT ratio of > 1 may suggest non-alcoholic fatty liver disease

Answer 118

The correct answer is: ERCP further determination of biliary duct dilatation

Answer 119

The correct answer is: HBsAg, IgM anti-HAV, IgM anti-HBc, and anti-HCV

Answer 120

The correct answer is: HBeAg appears concurrently with or shortly after HBsAg

Answer 121

The correct answer is: Booster immunizations are recommended routinely for hemodialysis patients

Answer 122

The correct answer is: Splenic Vein Thrombosis

Answer 123

The correct answer is: Portal hypertension: SAAG of 1.2 gm/dL

Answer 124

The correct answer is: Measure serum–ascites albumin gradient

Answer 125

The correct answer is: Alcoholic abuse

Answer 126

The correct answer is: Propranolol

Answer 127

The correct answer is: gallstones

Answer 128

The correct answer is: Trypsin

Answer 129

The correct answer is: Reduction of infectious complications is reduced with enteral route

GASTRO Flashcards

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