Gastro internal Flashcards
(210 cards)
1
Q
risk factors for Chron diesease
risk factors of UC
also protective
A
Chron’s
* Smoking (protective in UC)
* 1st related family member
* OCP- high risk
* malnutrition
UC
* smoking protect
* apendectomy protect
Both protective
* Breastfeeding
both risk
* Enteric inf. in 1st year of life
2
Q
Chron’s disease:
which place is highly invovle in the disease and whice place is spare?
A
Terminal ilium- most common (70%)
Spare- Rectal
3
Q
Cobblestone + creeping fat are both chracteristcs of
A
Chron’s disease
4
Q
What we will see on biopsy of Chron disease?
A
transmural Non-ceasting granulomas with lymphoctes infiltrates
5
Q
Chron disease
main areas of fistula?
A
- bladder (enterovesicle)
- Peri-anal
- Abdominal
6
Q
Ulcertive colitis will always start in which location?
A
Rectum- and then proceed proximal
involve the Colon only
7
Q
Which IBD is more common to see peri-anal disease?
A
Chron- 1/3 of pt
8
Q
Which layers of the colon are involve in UC?
A
mucosa + sub-mucosa
9
Q
What are the main skin menefistation of UC?
A
- Pyoderma gangrenosum- deep necrotic ulcer
10
Q
Which IBD is associted with Biliary stones
A
Chron disease
11
Q
Which IBD is more associated with PSC (primary sclerosing cholangitis)
A
UC
12
Q
Which kinds to kidney stones can be seen in a pt with chron’s disease
A
CaOXalate (after jujonectomy)
13
Q
Chrons disease
Which type of Extra-GI menefication are in correlation to the severity of the disease
A
- Arythema nodosum
- Peripharal arthritis
- Episcleritis- eye burning sensation
14
Q
what is the main skin menefistation of Chrons
A
- Arythema nodosum
can be also seen in UC
15
Q
Which type of seronegetive disease is can be ssin in UC and CD (more in chrons )
A
Ankylosing spondylitis
16
Q
Which type of arthritis can be seen in chrons disease
A
Migratory polyartiritihs
mainly of large joints
17
Q
Which type of medication use in IBD can cause pancreatitis?
A
mp-6
ASA-5
18
Q
where in the biliary tree Primary sclerosing cholangitis mainly damage?
A
intra + Extra biliary pathways
19
Q
what is the definitive Tx for PSC?
A
liver transplant
20
Q
how many pt with PSC will develop IBD (mainly UC) in some point of there life?
A
around 50-70%
but only 5% with UC will develop PSC
21
Q
what is the Gold standart for Dx PSC?
A
ERCP
BUT beacuse MRCP is more sensetive, specifc and safe- that will be the first dx test
today ERCP- for Dgx and Tx, today save for mainly Tx things- like stent insertion
22
Q
Tx for PSC if polyps are found in the gallbladder?
A
כריתת כיס מרה
23
Q
Which type of test are helping in distinguish IBD to IBS
A
Lactrofertin and Calprotectin in stool
Lactropertin- more sensetive for detect inflammation in the intestine
and the level is correlate to the histological inflammation
24
Q
Which type of cancer is a/w increase risk in pt taking AZA (purine analogs)- MP6, AZA
A
NHL
25
Anti- TNF in treatment of IBD is a/w increase risk to which type of cancer
melanoma + non melanoma
26
Tx for easy-mild UC disease
for remission and maintanance?
5-ASA (salazine suffix)
27
False / True
Steroids have part in IBD for remmisiona and maintanance
**FALSE**
Only in remission
28
Azathioporine in MP-6 are use in IBD for which stage of treatment
what is a major cons and serious side effect
for induction and maintance
cons- respond takes time ~ 4-6 months until reasults
S.Effect:
* BM suppresion- mainly meyoilpania
* Pancreatitis
* Hepatotoxicity
* High risk for NHL + non melanoma
29
Combinaiton of Purine analogs (6-MP + Azathioporine) with which types of medication can cause severe side effects of purine analogs?
**Xhantine oxidase inhibitors- give in GOUT = Alloperinol**
must adjust and lower the dose of the purines analog if using toghther.
30
Side effect in the GI of MTX
Apthous Somatitis
31
Which medication can be use for severe refactory UC which resistant to biology and steroids Tx?
**Cyclosporine**
for induction
watch for hyperkalemia, AKI, infections
32
Which anti TNF is for Chrons
which type for UC
and which type does not fit IBD at all?
For **c**hrons- **C**ertolizumab
for UC- Golimumab
all SC except Ifliximab (IV)
**ETanerecpt- not good for IBD (only SpA and RA) **
33
Major side effect under ani-TNF
* Creation of Ab (more in ifliximab)- not nessecerly C/I
* Reactivation of TB and HBV- must chech prior start
* Risk for Melanoma and non-melanoma
* Drug induce SLE
34
What is the major advantage using **Vedolizumab** for IBD
**Selective immunosupressive for intestine w/o damage in the systemic immunity**
could be use as first line or after Anti-TNF failure- for UC and CD
| עושה וודו בבטן
35
Which medication can be use in mild-severe IBD **mainly if ** psoriatic arthritis is present
**Ustekinunab**
anti-IL12/23
36
Which test we will must do prior the Tx in biologic medications
TB > 5mm + HBV
natalizumab- JC virus
Tofacitinib- immune for Shingrix (varicella zoster)
in all- pervner 13 >> pneumovax 23
37
Which types of Abx are used in IBD, for which conditions in CD vs UC
**Flueroquinolone (Ciprofloxacin) + Metronidazole (Flagyl)**
**UC-** Pouchitis (complication of IPAA) **only!**
**CD-** in fistula disease
## Footnote
**ileal pouch–anal anastomosis (IPAA)** is a surgical procedure that is used to restore gastrointestinal continuity after surgical removal of the colon and rectum
38
line of Tx in easy-mild Ulcertive colitis
and what if that mild-severe UC?
**for easy-mild UC**
5-ASA (PR/PO) > local steorids (budosemide) >> systemic steroids >> biology with / not purines analog or MTX >> Tofacitinib (Jak)
**For mild to severe UC**
start from Systemic steorids >> biology with / not purines analog or MTX >> Tofacitinib (Jak) >> Cyclosporin IV
## Footnote
Rember- Cyclosporine only for refactory severe UC
5-ASA- only in easy UC
39
When in Chrons disease **we will never give Steroids**
Fistula
40
What is the most final line in Chron disease Tx?
intenstine rest + TPN
41
What is consider a rescue therapy in severe UC prior Colectomy?
Infliximab + Cyclosporin
42
What is the Surgery of choice in UC?
IPPA- keep the anal spincter
| 30-50% will have complication
## Footnote
**The ileal pouch–anal anastomosis (IPAA)** is a surgical procedure that is used to restore gastrointestinal continuity after surgical removal of the colon and rectum
43
What is pouchitis?
Complication of IPAA
| עלייה בתדירות היציאה, צואה מימית, דלף לילי, חולשה וחום
## Footnote
ביופסיה תעזור לזהות האם מדובר בקרהון חבוי
44
Main C/I for IPAA
Chrons disease
45
Which medications in IBD are C/I
MTX
Tocacitinib (anti-JAK)
Abx: Metronidazol (1st trimester) flouroquinolones
46
What is the increase risk for Colorectal cancer in IBD
1.5-2 times fold
47
When we will screen IBD pt for colonrectal cancer
1. **8-10 years after onset** in pt with more then** 1/3 colon involve**
2. **12-15 years from onset** in pt with **proctosigmoiditis**
## Footnote
colonoscopy every 1-2 years for pt with chronic colitis
48
What is the managment of finding in colonoscopy in chrons?
for:
polyp
Adenmoa low grade
adenoma high grade
* polyp- endoscopial removal
* Adenmoa low grade- coloctemoy
* adenoma high grade- colectomy in UC, colectomy / local inscion in CD
49
Which medication can cause Drug induce colitis (which can be confusing with IBD)
**Immune checkpint inhibitors**
Anti-CTLA4
Ipilimumab
## Footnote
can tx with steroids
if severe- immuno-modulators- Anti-TNF + integrins inhibitors
50
What is **Microscopic colitis**
age, presentation
and what ae the 2 varients
Tx- 1st line and refactory cases
most common interstinal disease in **older pt 60-80**
only histologic findings, chronic watery diarrhea
**lymphocytic varient-** close a/w celiac
**Collagenous-** collagen depositing in sub epithal (women > man)
## Footnote
1st line- 5ASA, bismuth, budosonide
refoctory- purine analogs (MP-6, AZA = imuran)
51
True or false
ALT and AST are correlate with thr sevirty of liver damage in viral hepatitis
**false**
52
way of infections in HBV
* Vertical - maternal-fetus
* sex
* blood
53
Which marker in HBV infection will be **the only one** to be elevated in the window period
anti-HBcAb IgM
54
Which marker will be elevated in infetion (chronic or acutic in HBV)
HBsAg
if recovery- HBsAb
55
The different between a man who was vaccinated to HBV and a man infeted in recover from HBV
vaccine- only HBsAb
recover- HBsAb + HBcAb IgG
56
Which Ag is in correlation to the infectivity of the HBV in a body
HBeAg
| some pt have virus that mutant and not present this Ag
57
What is the most earliest marker of HCV infection
PCR-**HCV RNA**
| gold standart
58
Autoimmune disease correlates with HBV
and another one that correlate with HCV
HBV- polyarthritis nodusa (PAN)
HCV- Cryoglobilunemia
59
Which hepatitis can be fulminant in pregnancy (%?)
and how can be infected
HEV
Feco-oral by contamination of water sources
| 15-25% in pregnancy mortality rate
## Footnote
1-2% fulminant with mortality rate in rest of population
60
Tx for Chronic HBV?
and also HBV+ HDV?
INF-alpha
61
Tx for Autoimmune hepatitis
prednisone, AZA
62
What is the most improtant prognostic feature in HBV
**Viral load- HBV DNA**
| not in acutic hepatitis - only in chronic
## Footnote
goal- decrease replication of the virus
63
Which family medication can cause resistance in the Tx for HBV
Nuecleotide Revese transcriptase inhibitors
| Lamivudine- is the most
64
Which family medication against HBV can be use in chirrosis
Nuecleotide Revese transcriptase inhibitors
| also after liver transplant and immunodepressent
65
What is the duration of therapy in NRTI and PEG-INF
NRTI >1 year. mostly for life (daily oraly)
PEG-INF , 48 weeks
66
Which Medications are use as pre-PPX for HIV
(PrEP)
Tenofovir + Emitricitabine
also use for HBV
| type I HIV
67
What is the backbone of Tx in HIV ? meaning which medication usally combine
2 NRTI + 1 Integrase inhibitor
**NRTI will be never administered as monotherapy**- also true for HBV
68
PEG-INF vs NRTI (nucleoside RT inhibitors)
* in which type theres no resistance at all?
* in which therse more change of disappering of HBsAg?
PEG-INF = no resistance
+ more chances of HBsAg clearance (12%~)
69
**PEG-INF**
* C/I
* How many Seroconversion in the end of the 1st year of tx
C/I- chirossis, liver transplant, immunodepressant pt
Seroconversion at end of 1st year ~30% (NRTI- 20%)
70
HBV + liver transplant post Tx?
| for prevent recurrence
1. passive immunization
2. NRTI (Tenofovir / Entecavir)
71
When we treat in HBeAg positive?
Viral load > 20K + ALT X2 UNL
| Antecavir/ tenofvir / INF
## Footnote
if not- we are not treating unless age > 40 or advance disease
72
Tx for HBV with chirrosis?
always treat with- **DNA > 2000**
non compensate - **DNA is measurable**
## Footnote
C/I for PEG- INF
73
Tx for Pt with negetive HBeAg?
same as with positive HBeAg but now its not 20K it 2000.
## Footnote
Viral load > 2000 + ALT X2 UNL
74
difference between co-infection and super infection HDV
**co-infection-** B + D at same time >> like acute HBV symptoms
**Super-infection-** chronic B + D on top >> Flate of harsh hepatitis
75
What is the classic Ab for HDV
LKM3
76
What is the only tx for Hep D infection?
INF-a
high dose at least for a year
77
How many pt infected wth HCV will progress to Chronic?
~85%
## Footnote
in HBV- 90% peri-natal, 50% children, 10% adults
78
Lichen planus, B cell lymphoma, cryoglobelinumea are all a/w which type of viral infection
HCV
79
What is the most prognostic factor in HCV infection ?
Level of fibrosis
| in HBV- the viral load
80
Defintion of cure from HCV
12-24 weeks post tratemnt without trace of virus in blood
**SVR- sustained virological response**
81
Which DAA is C/I in uncompensated chirrosis?
Protease inhibitor (NS34A)
82
What is the C/I for sofobuvir (NS5B)
* Amiodarone
* renal insuff.
83
Which Ab is associated with Autoimmune hepatitis
ASMA
anti-smooth muscle Ab
| ANA more specific- also +
84
all of the following are pointed to which diagnosis?
ANA +
ASMA +
eleveted IgG
Anti-LKM1
HLA-DR3/4
AIH (autoimmune hepatitis)
85
What are the indication for Tx in AIH?
Aminotranferase > 10X or > 5X + hypergammaglobulinemia > X2
## Footnote
אין אינדיקציה לטיפול במחלה קלה- לא הוכח יעילות
86
What is the** induction** therapy include in AIH?
* main- Steroids (60 mg >> 20 mg maintainance)
* another option- prednisone half dose + AZA - **less steroids complications**
| always with steroids, AZA never alone in induction
## Footnote
maintance for 12-18 months
87
What is the **maintainance** therapy for AIH?
1. low dose prednisone (10mg)
2. AZA alone- 2 mg **more effective for remmisoon**
88
What is the most common cause of liver transplant in USA?
NAFLD
| non alacholic fatty liver disease
89
Dx of NAFLD?
**MRI/CT/US-** Fatty liver w/o story of alcohol consumption
| must rule other causes
90
How to differ between NASH to NAFLD?
**Biopsy gold Standart**
91
True or false?
Theres no Tx that have been proved in improving prognosis of NAFLD pt
**True**
but can give some things if indicated:
Statins, Thiazides, liver transplant (alotugh NAFLD can reaccure)
92
Which factors takes into account in **Child-Pugh** and what does this score means?
**a scale for the severity of the chirossis in correlation for survival in complications**
1. Bilirubin
2. INR (PT)
3. Albumin
4. asictes
5. encephalopaty
A- compensate
B/C- non-compensate
| 3 labs + 2 clinical
93
what is the score use for Desicion of liver transplant?
**MELD score**
* Bilirubin
* Creatinine
* INR
94
Which clinical finding can be found in alcoholic liver chirrosis
AST > ALT
2:1
Ig-Alcohol can be eleveted
95
Primary biliary cholangitis
* part of the biliary tract
* Ab
* prevalence
* **small -medium biliary tract**
* Ab- **AMA (anti-mitochondrial)** > 95% *IgM could also rise*
*
* prevalence- womens in their ~50
| ALP + GGT elevated.
## Footnote
AMA- sp100 or gp200
96
how we Dgx PBC?
* **elevete cholastatic enzymes + positive AMA**
* if AMA negetive - liver biopsy + cholangiography for rulling PSC
## Footnote
negetive AMA does not rule PCS (remember? its not 100%)
97
Tx for PBC
UDCA (ursodeoxycholic acid)- first line
**liver transplant-** uncompensated chirrosis
**symtomatic Tx-** Vit.D + clacium- prevent osteopnia, for pruritus
98
Primary Sclerosing cholangitis
* part of the biliary tract
* Ab
* Which autoimmune disease is strongly a/w
**all biliary tree will be involve**
Ab- 65% with p-ANCA
**IBD (UC mainly)**- 60-80% of pt with PSC
99
How to Dgx PSC?
**MRCP- test of choice**
Stenosis and beadingin biliary intra-extra hepatic
100
Tx if risk to bleeding from vericles in chirrosis?
**Non-Selective BB**
Nodolol / proprenolol/ carvidelol
**or**
**EVL )Vericle ligation**- קשירת הדליות
101
Tx in Upper GI bleeding
1. Octerotife - somatostatin analoge = vasoconstirction of Splenchic, **not replace ligation**
2. Abx PPx- mainly rochein (Ceftriaxone) for 7 days
3. **Temponade by balloon-** until endoscopy or TIPS
**Endoscopy and EVL- first line and usually the definitive Tx**
| No Tx with BB in acute setting
102
When we will preform **TIPS**
Bridge to Liver transplent
for people who fail in endoscopy (bleeding remain despite therapy) / C/I for it **or for second prevention**
103
How many pt will gain control on the upper GI bleeding in EVL , what can be the complication?
90% will gain control
complication- ulcer in the base of the vericle or esophagus stenosis
104
What is SAAG?
What is SAAG > 1.1
SAAG < 1.1
Serum the albumin ratio- for evaluation of the ascites/
SAAG > 1.1 = chirrosis, mean that there portal HTN
SAAG < 1.1 = infection or malignancy
105
What is the total protein in Ascites from CHF vs Chirrosis?
CHF - total protein > 2.5
Chirrosis - total protein < 2.5
in both SAAG > 1.1
106
When Ascites have total protein below 1.5 what we should think about?
SBP
107
Lines of Tx for Ascites
1. Sodium uptake < 2 gr/day
2. Spironolactone and fusid
3. refactory- ניקוזים חוזרים
4. TIPS and consider liver transplant
## Footnote
כשמבוצעים ניקוזים חוזרים- על כל 5 ליטר צריך להחזיר 8 גרם אלבומין על כל ליטר שהוצא
108
When SBP will be suspected to be peritonitis secondary to perforation
if more then 2 bactria are grow. **SBP is one bug disease**
need to do abdominal imaging
109
Dgx of SBP?
and Tx?
* ascites with > 250 PMN **this is the definition of SBP**
* Ceftriaxone / Tazosin 5-14 days
* Albumin IV - reduce mortality in high risk pt
110
PPX for SBP
what we give and for who?
* **pt with prior SBP infection**- fluroquinolones / resperim
**primary prevention- for 7 days Ceftriaxone**
* **Total protein < 1.5**
* **Pt hospitelized with Upper GI bleeding**
111
Definition of hepato-renal failure and what is the Tx?
Pre-renal AKI w/o response to fluids.
Tx:
1. **Albumin-** 1gr/kg Xday
2. **Terlipressin / low dose NE**- vasopressors
3. **Liver transplant-** definite Tx
| can also use octerotide and midodrine
## Footnote
cause by vasodilation of the splenchin and hypoperfusion of the kidney
112
common physical sign of hepatic encephalopathy?
Asterixis- Flapping tremor
113
Main Tx in Hepatic encephalopathy?
| 2 main tx
1. **lactulose-** reduce the amount of amonia absorbeb
2. **Rifaximin-** low dose of amonia inducing bacteria
114
Absolute C/I for liver transplant
* **AIDS (not HIV)**
* advance cardiopulmonary diseasecholangiocarcinoma
* exta-hepatic malignancy
* uncontrol sepsis
**relative C/I**
HIV CD4 < 100
age > 70
HCC- only if sole lesion < 5 cm or 3 lesions < 3 cm each one
115
What is the leading cause of acute liver failure?
**DILI**
| Drug induce liver injury
116
**paracetamol toxicity**
* what is the toxic metabolite
* max. dialy dose for paracetamol
* Tx?
Toxic metabolite- **NAPQI**
max daily dose-** 3 gr**
Tx- **N-acytl cysteine**
## Footnote
שטיפת קיבה, פחם פעיל או כוליסטיראמין- רק תוך חצי שעה מנטילת התרופה. קודם שטיפה ואז תרופות
117
How we asses the severity of damage in paracetamil toxicity?
level of medication after 4 hours
118
שטיפת קיבה, פחם פעיל
ו- Cholestyramine
יכולים להינתן באיזה חלון זמן בהרעלת אקמול?
תוך חצי שעה מנטילת התרופה
נתחיל עם שטיפת קיבה
119
Which substance/ disease can increase the toxicity of paracetamol
* Alcohol consmption- more then 2 gr is toxic
* hunger
* HCV
* phenobarbital/ isoniazid- indict CYP
| בשחמת כבד אקמול נסבל היטב ולא מעלה סיכון להרעלה
## Footnote
thing that increase CYTp450
120
When we wil administer N-actyl cysteine?
**after 4 hours- ** Paracetamol level > 200 mgr
**after 8 hours-** > 100
| IV loading dose and then every 4 hours
121
Which lab finding uncer paracetmaol toxicity can predict the need of liver transplant?
Lactale levels > 3.5
122
What is the most common medication to cause DILI in the USA
**Augmentin**
increase mainly ALP and GGT
| Amoxiciliin / calvilunate
## Footnote
could present after latent phase / end of Tx/
123
Why the liver damage can persist long after stop taking Amiodarone?
due to its long half life
124
Which DILI can cause transient elevation in liver enzymes?
* Prukor (amiodarone)
* Valporate
* Isoniazid
and Statins- a-symptomatic. no need to monitor
| אופ עבר- איזוניאזיד / פרוקור וברפוראט
## Footnote
עלייה קלה וחולפת
125
Which DILI can cause chronic heptitis w/o any distinction from AIH (AMA , ANA- ASMA)
**Nitrofurantion**
126
What we will see in biopsy of DILI by Resperim (SMX-TMP)
Granulomas + Eosinophilia
## Footnote
could menifest as DRESS syndrome- rash and systemin HSR IV
127
Which para-neoplastic syndrome are a/w HCC?
Hypoglycemia
Arythrocytosis
128
Which marker can be eleveted in HCC?
**AFP = alpha feto protein**
## Footnote
could also be eleveted in liver chirrosis
129
Which pt's will be screen for HCC and in which interval
**abdominal US every 6 month with or without AFP levels**
1. chirrosis pt (except Child C)
2. HCV with adv. fibrosis
3. HBV + age > 40 / >20 in Africans. family Hx HCC
130
How we Dgx HCC in chirossis pt vs non-chirrosis pt?
**MRI or Tri-phase CT**
only when:
lesion > 1 cm
+
fast adhere in artry phase and washout in portal phase
## Footnote
**In chirrosis-** no biopsy needed unless imaging was inconclusive
**not chrrosis-** biopsy
131
# HCC
Which pt are candidate for Ablation?
phase 0 = lesion < 2 cm
or
phase 1= who cannot go trough resection
132
# HCC
Which pt are candidate for resection?
single lesion > 2 cm + Child A with normal bilirubin and no Portal HTN
## Footnote
CHILD- bilirubin, albumin, PT (INR), ascties, enecephalopathy
133
Which pt are candidate for liver transplant
one lesion > 5 cm
or
3 lesion < 3cm
**can done in any stage of chirrosis including portal HTN**
134
Which Tx for HCC are paliatve treatments?
* Chemo-embolization
* Systemic tx
135
When should we give adjuvant therapy in HCC?
**never**
136
which malignant is **highly** a/w NAFLD
Cholangiocarcnimoa
137
A male present with incident lesion on liver US. he knows to be taking anabolic steroids.
what is the workup regarding that pt?
1. look for **CTNNB1** mutation
if positive- ** resection and biopsy**
CTNNB1 + male + anabolic steroids- increase risk for HCC
138
T for Hepatic adenoma
| lesion > 5 cm, lesion < 5 cm, Bleeding
* **lesion > 5 cm - **Resection
* **rest-** loose weight / stop OCP/ steroids- follow up in 1 yr
* **Bleeding adenoma-** ambolization > resection
| CTNNB1- always resection
139
most common benigh lesion in liver?
Hemangioma
140
Dgx of liver adenoma
CT/ MRI - MRI better
141
Levels of workup in iron def. anemia in male (any age) _ post-menopausal womens
1. Colonoscopy (even if negetive stool blood test)
2. Gastroscopy- if colonscopy is ok and consider take biopsy for celiac
*is both test are normal- consider assesment of the small intestine by capsule, CTE, MRE, enteroscopy
| Colonoscopy >> Gastroscopy > consider Small intestine
142
What is mallory -weiss tear
| which cindition is highly a/w, where is the pathology, dgx?
mainly a/w vomiting
tearing of the esophagus-kideny junction
Dgx- Endoscopy
143
Triad of Ascending cholangitis
**Sharko:**
Jaundice, RUQ pain, fever
144
Tx for Ascending cholangitis
1. hydration + Abx IV
2. drainage gallbladder by ERCP
145
Which clinical findings Asecnding cholangitis is realted to high mortalitiy and what is the tx
**Renu pentad:**
Jaundice
RUQ pain
Fever
**Shock
COnfusion**
| Tx- urgent drainge of billiary tract
## Footnote
התערבות דחופה
146
How we asses the severity of UGIB?
סימני אי יציבות המודינאמיים
147
Which pt should undergo urgent gastroscopy < 12 h in UGIB?
| most will need gastroscopy in 24 hours
* Hypotension
* Reccurent hematemesis
* זונדה דמית לא מצטללת אחרי שטיפה בנפח גדול
* need of blood transfusion
148
Test of choice for LGIB
Colonscopy
אלא אם כן חוסר יציבות המודינאית ואז נתחיל בגסטרוסקופיה לשלילת דימום ממקור עליון
## Footnote
Urgent colonsocpy- wprepare with polyethylane glycol PO
149
Which risk is a/w **PEG** and in what %?
mainly infection of the wound in 10-15%
150
what are the major risk of Endoscopy?
Bleeding and perforation
## Footnote
in diagnosis- 1:1000 > risk
in Tx- 0.5-5%
151
Which risk is a/w **ERCP** and in what %?
Secondary pancreatitis - 5-25%
usually mild and self limited
152
in which ensocopic procedures we will always give PPX?
PEG
chirossis + UGIB
and other when we are dealing with cyts and sterile lquids
153
What are the low risk procedures in GI?
what is the managment regarding stopping anti-coagulation / anti-plt
* Gastro/ colono- with or w/o biopsy
* EUS w/o FNA
* ERCP with stent replacment
**no stopping anti-coagulation / anti-plt**
| all the rest are high risk
154
When we will strat screening for CRC **no high risk** pt
age > 45
asymptomatic
**every 10 years**
155
When to screen pt after CRC?
1 year
156
When to SCREEN UC or Chron colitis for CRC?
evey 1 year after 8 years from diagnosis
if left colon after 15 years
157
Screenig of HNPCC (lynch) and FAP for CRC
FAP- age 10-12 every 1 year
HNPCC- age 25 every year
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Screenig of CRC in first dagree relative with CRC
10 years prior the onset of disease or at age 40 (the sooner)
if relative age > 60 - every 10 years
if relative age < 60 or 2 or more 1st dagree relative- every 5 years
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Which mutation is present in HNPCC ? (Lynch)
| and what are the criteria
MLH1 + MSH2
AD
## Footnote
proximal CRC
**criteria**
1. 3 or more relatives with CRC
2. at least 1 relative first degree
3. at least 2 generation
4. at least one dgx < 50
160
most common cause of peptic ulcers
NSAIDS
H.pylori- 30-60% in stomach, 50-70% n deudonum
161
which types of ulcers must rq biopsy?
**Ulcers in stomach**
mostly benigh- Antrum + distaly
| In deudonum- mostly small < 1 cm and benigh
162
Waht is dyspepsia?
when we will see it
אי נוחות, מלאות ונפיחות בטנית סביב אוכל
| **Related to peptic ulcers**
163
What is the workup for new onset dyspepsia ?
**age > 40 **- Endoscopy
**age < 40**- Test for H.pylori >> if positive treat for 4 weeks and confirm eradication. if not H.pylori- try H2 blockers and if not resolve >> endoscopy
164
Tx stages in H.pylori?
1. Triple therapy - 2Abx + PPI 14 days
2. H2 blockers / PPI- 4-6 weeks
**after- 4 weeks from Abx / 7 days fro PPI- check for eradication**
165
What is the managment of negetive biopsy on peptic ulcer in the stomach?
8-12 weeks later repeat endoscop- to check of healing
| **if deudunom -** reccurent endoscopy only if symptoms continue
166
Which Abx can be less absorbed when using PPI?
Ampicillin
Fluroquiolones
167
Which electrolyte disbalance can PPI cause?
Hypomagnesemia
168
What is the main surgery Tx in duedenal ulcers?
**Vagetomy**
169
What is dumpling syndrome
when the intestine is too short- after carbohydrate meal >> hyperosmolar in lumen >> more water secrete >> diarrhea, tachycardia, nausa...
late- symptoms of hypoglycemia
**tx- low carb diet**
170
Most common complication of ulcers
and what are the total 3 complications
1. Bleeding- **most common** > 50% will bleed are a-symptomatic
2. Perforation- more in NSAIDS- zonda, IV PPI, Abx, surgery consolt.
3. obstraction of exit of the stomac- endoscopy balloon
171
Which cancers are a/w H.pylori
MALT lymphoma (NHL- marginal zone)
Gastric adenocarcinoma
172
Tx for H.pylroi
1st line
2nd line
1st line- Amoxicillin + Clarithromycin + PPI
2nd line- Amoxicillin + Tavanik + PPI
**only after failure of 2nd line >> Endoscopy with multiple biopsy's**
## Footnote
**if amoxci sensetive- Metronidazole**
**If clarithro sensetive- Tetracyclin + bismuth**
173
What is the reason of Zollinger allison disease
**Gastrinoma**
neuroendocrone tumor secrete gastrin >> lots of peptic ulcers
174
What is the gastrinoma triangle?
Pancreas- Head and body
Deudenum- 2-3 part
Biliary tract
## Footnote
most gastinomas in Duedonum > pancreas
175
Which type of hearidtery diasese ic correlate with gastrinoma in pancreas?
MEN 1-
PPP
Para-thyroid
Pancreas
Pituatary
176
Most common presentation of Gastrinoma
* Abdominal pain + peptic ulcers > 90%
* diarrhea > 70%
177
What is the screening test for Gastrinoma?
**Fasting gastrin test**
must stop PPI a week prior > H2 blockers > PPI 12 hrs before
Normal < 150
| **need to do twice- if low in twixe = rule out**
178
Test to establish Gastrinoma
1. **Fasting gastrin X2** > 150
2. **stomach PH** - < 3
3. **Secretin test-** > 120 in gastrin 15min after secretin
4. **PET-CT in DOTATATE-** location and metastasisi > 90% specifity and sensetivity
179
Test of choice to find gastrinoma and possible metastasis?
**PET CT DOTATATE**
| Detect neuroendocrine tumors
180
Symptomatic Tx for gastrinoma?
* **PPI- main choice**
* **Octreotide-** if tumor present receptors for somatostatin can be added to PPI
| if no metastasis- Surgery for removal
181
What is the most significant prognostic factor in gastrinoma and what it reflect on the survival rate in 5 years?
**Present of metastasis**
20% survival in 5 years
182
How to differente between motiliy to stractral abnormality oin esophagus?
motility- solids and liquids
stractural- solids progress to liquids
183
Which type of hernia is associate with esophagus injury?
Hiatal hernia
type 1- older, most common, increase abdominal pressue, high GERD risk
type 2- require repair
184
What is Schatzki ring
stenosis in ECJ < 13 mm
soilds dysphagia
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Zenker diverticulum
location
pathophysiology
Dgx
Tx
* **location**- between esophagus and phrynx
* **pathophysiology-** damage in muscularis and false diverticulum of the mucosa + submucosa. **higly a/w cricohryngeal muscle**
* **Dgx-** barium swallowing test
* **Tx-** diverticulectomy / closer of diverticuli/ cricoharyngeal myometomy
| Helitosis- badbreath smells + dysphagia
186
What is Acelasia?
clinical presentation?
which type of cancer association?
* **Acelasia-** hyperactive LES + absance of peristaltica
* dysphagia- **solids + liquids**
* **SCC**
187
Classic finding of Achalasima in Barium and monometry?
which one is more senstive
Tx?
Barium- Bird beak apperance
monometry- increase tonus + no peristaltica
**monometry is more sensetive**
Tx- lower stress on LES. no curable treatment
1. CBB / nitrates- not that effective
2. Botolinum toxin LES (6 months)
3. **Pneumatic dilation-** endoscopy
4. **myotomy**
188
Which patoghen have a protective effect agaisnt GERD?
H. pylori
(reduce acid)
189
TRUE or FALSE
in GERD the severity of symptoms is in correlation to the endoscopic finding
**False**
| no correlation
190
Dgx of GERD
1. high clinical susepct + good respond to PPI
2. PHmetria (most sensetive) + endoscopy- when Dgx is not clear. **positive PH < 4 most of time**
3. Gastroscopia- if red flags
191
Most significant complication of GERD
1. Barret- **metaplsia**columnar no ciliated glandular epithel
2. Esophagus Adenocarcinoma- from Barret's
192
When we will perform **Ablation** in Barret's esopahgus
**High grade dysplasia**
193
Which infections can cause esophagitis?
* **CMV**- CD < 50, Gancyclover or Vangancyclovir 36 wks
* **HIV**- acute disease
* **Candida-** fluconazole 14-21 days
* **HSV-1**- Acyclovier
194
What is the DDx for GERD with biopsy showing eosinophils?
Eosinophilic esophagitis
**inflammation with eosinophils dominance**
195
Tx for Eosinophilic esophagitis
PPI
proper diet
Steroids- budosonide
196
Which medication can cause esophagitis?
| 7 medications
* Bi-phosphonates
* NSAIDS
* Tetracyclins (doxycycline)
* Quinidine
* KCL
* iron-sulfate
* phyntoin
197
Which HLA are a/w celiac disease?
| and what does it prevelance?
HLA-DQ8
HLA-DQ2
| > 99% of pt will have them
in general poulaiton- 25-35%
## Footnote
**if negetive = > 99% no celiac disease**
198
Which autoimmune disease are a/w celiac?
* DM1
* Hasimoto
* Dermatitis herpetiformis
* IgA def.
199
Which Ab are a/w Celiac disease
1. Anti-Gliadin
2. Anti-endomysial
3. Anti- TTG IgA
Check for IgA levels- Def. can cuase FN
| **GET** Celiac test
200
gold standart for celiac Dgx?
Ab + Biopsy (no villi, hyperplasia of crypts + lymppcytes)
201
Which cancers are a/w celiac disease
T cell lymphoma
small intestine adenocarcinoma
202
Tx for celiac
bo gluten diet- response in ~90% of pt
203
When we will see small bowl bacterial overgrowth?
disease that damage the motility of proximal small intestine or reasult in stasis
Scleroderma
Chron's- strictures
Diverticulosis
| **Remember- motility problem or obstruction**
204
What is the clinical presentation of small bowl bacterial overgrowth
1. malabsorption, diarrhea, statorrhea
2. bloating
3. B12 def. with high folate
205
Gold standart for Dgx- small bowl bacterial overgrowth
**Bactrial titer from deudenal aspiration- gold standart**
206
Tx for Bacterial overgrowth in small intestine?
**Rifaximin**
| other Abx: Metronidazole (flagyl), doxy, Cephalosporins
207
What is the amylase levels in blood and urine in Macroamylasemia?
amylase blood- high
urine- low
| 1.5% in hospitelized adults who are not alcholoic
## Footnote
amylase is a large polimer >> cannot secrete in urine
208
How we Dgx IBS?
**Rome Criteria**
1. reccurent Abdominal pain ,at least 1 day X week, in last 3 month + at least 2:
a. Related to defecation
b. a/w change in frq of stool
c. a/w change in form of stool
## Footnote
לסיכום:
כאב בטן לפחות פעם שבוע במשך 3 חודשים + קשר לקקי:
1. קשור לקקי- הכאב
2. בא עם שינוי בצורה של הקקי
3. בא עם שינוי בתדירות הקקי
209
Which Abx can help to relieve the symptoms in IBS
Rifaximin
210
What are the 3 main indication for liver biopsy?
1. heptocellular disorder from unknwon cause
2. suspiction for HIA
3. Hepatomegaly from unknown cause
| no need biopsy:
fatty liver
chirrosis
HCV, HBV
respont to tx for AIH
