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Flashcards in Gastroenterology Deck (70):
1

42M
diffuse abdominal pain
pain began 2 days ago after a long night of drinking in his favorite bar
PE; febrile with notable epigastric tenderness
WBC 15.2
Serum amylase 950 U/L

Diagnosis?

Acute pancreatitis

2

Acute pancreatitis:
most common cause?

gallstones > alcoholic drink binge

3

Acute pancreatitis:
other important causes?
(besides gallstones and alcoholic drink binge, GET SMASHED)

GET SMASHED
Gallstones
ERCP
Trauma
Steroids
Mumps
Autoimmune / Alcoholic drink binge
Scorpion bite
Hyperlipidemia
Drugs (antivirals)

ART: ALL (Pancreatitis, Asparaginase)

4

Acute pancreatitis:
characteristic signs of PE

Gray Turner (flanks)
Cullen (periumbilical)

5

Acute pancreatitis:
most common appropriate diagnosic test?

serum amylase --- more sensitive --- snout with amylase
serum lipase --- more specific --- spin with lipase

6

Acute pancreatitis:
important imaging study should be done?

abdominal CT scan showing sentinel loops

7

Acute pancreatitis:
mot appropriate treatment?

bowel rest (NPO)
hydration
analgesics

8

Acute pancreatitis:
most important analgesic?

Meperidine --- does not cause SO dynsfunction

9

Acute pancreatitis:
complications?

hemorrhage
pseudocyst --- normally, the mesentery has no epithelium
chronic pancreatitis --- malabsoprtion

10

Acute pancreatitis:
criteria used for prognostication?

Ranson's Criteria

11

Acute pancreatitis:
Ranson's Criteria components?

GALAW CHPBBS

At presentation:
Glucose
Age
LDH
AST
WBC

At 48 hours:
Calcium
Hematocrit
pO2
BUN
base deficit
sequestration of fluids

12

Acute pancreatitis:
how is prognostication done using the Ranson's Criteria?

Score of:
0 to 2 --- 2% mortality
3 to 4 --- 15% mortality
5 to 6 --- 40% mortality
7 to 8 --- 100% mortality

13

Acute pancreatitis:
are antibiotics indicated for this condition?

antibiotics indicated in severe pancreatitis with >30% necrosis on CT scan

14

Acute pancreatitis:
surgery indicated?

pseudocyst
abscess
biliary pancreatitis

15

Acute pancreatitis:
clinical presentation of chronic pancreatitis

abdominal pain with signs of malabsorption due to pancreatic insufficiency

16

Acute pancreatitis:
most common cause of chronic pancreatitis?

long term alcohol abuse

17

Acute pancreatitis:
what is treatment for chronic pancreatitis?

dietary modification (small low fat meals)
enzyme replacement (pancrelipase)

18

45M
smoker
dysphagia
weight loss
history of recurrent burning chest pain after meals
chronic cough
appears cachectic
PE is unremarkable

Diagnosis?

Esophageal adenocarcinoma

19

Esophageal adenocarcinoma:
risk factors?

achalasia
Barrett esophagus
cigarette smoking
diverticula
ethanol
familial

20

Esophageal adenocarcinoma:
most appropriate diagnostic test?

barium swallow
followed by EGD with biopsy

21

Esophageal adenocarcinoma:
biopsy?

squamocolumnar metaplasia (Barrett esophagus) and neoplastic changes (invasion)

22

Esophageal adenocarcinoma:
most appropriate treatment?

esophagectomy (resect) with gastric pull up +/- chemoradiation (controversial)

23

Esophageal adenocarcinoma:
two types of esophageal cancer and associated conditions?

Barrett esophagus with esophageal adenoCA
Plummer-Vinson syndrome with SCCA

24

Esophageal adenocarcinoma:
localization and incidence

now equal in incidence
esophageal adenoCA in distal 3rd
esophageal SCCA in middle 3rd

25

Esophageal adenocarcinoma:
who will you differentiate esophageal CA from achalasia clinically?

achalasia: dysphagia to solids and liquids simultaneously

esophageal CA: dysphagia first to solids progressing to liquids

26

Esophageal adenocarcinoma:
If patient were an alcoholic with frequent retching and vomiting --- leading to severe hematemesis --- diagnosis?

Esophageal rupture

27

Esophageal adenocarcinoma:
differentiate the two most likely causes of esophageal rupture

Mallory Weiss Syndrome: partial thickness tearing at GEJ
Boerhaave's Syndrome: full thickness tearing at GEJ

28

Esophageal adenocarcinoma
Esophageal rupture:
Management for Mallory Weiss Syndrome and Boerhaave's Syndrome

Mallory Weiss Syndrome: hemodynamic stabilization, EGD (diagnostic and therapeutic)

Boerhaave's Syndrome: antibiotics, surgery, IV hydration (almost 100% mortality)

29

33M
lawyer
burning epigastric pain, worsens when he is hungry, relieved by food
pain awakens him at night
due to work related stress, he often gets severe headaches for which he takes up to seven aspirin tablets a day
aside from epigastric tenderness on palpation, PE is unremarkable

Diagnosis?

Pepetic Ulcer Disease (most likely duodenal)

30

PUD:
underlying pathology?

gastric acid hypersecretion leading to ulcers

31

PUD:
most appropriate diagnostic test?

endoscopy with biopsy

32

PUD:
conditions encompassed by this?

gastric ulcers and duodenal ulcers

33

PUD:
most common location?

duodenal bulb

34

PUD:
differentiate two types clinically?

gastric ulcer: pain worse on food intake, not nucturnal pains
peptic ulcer: pain relieved with food intake, awakens patient at night

35

PUD:
most appropriate treatment?

PPIs
if positive for H. pylori, give omeprazole + clarithromycin + amoxicillin

36

PUD:
possible complications?

hemorrhage > perforation > gastric outlet obstruction

37

PUD:
treatment when refractory to medical management?

duodenal ulcer: truncal vagotomy with pyloroplasty
gastric ulcer: BIllroth I or II reconstrucion

38

PUD:
patient continues to be refractory to management --- CT scan revealed pancreatic mass --- diagnosis?

Gastrinoma (Zollinger Ellison Syndrome)

39

PUD:
most common anatomic location of gastrinomas?

Passaro's Triangle
Junctions of CD/CBD/2D and 3D/head or neck of pancreas

40

PUD:
most appropriate diagnostic tests?

Pentagastrin stimulation test
Secretin stimulation test

41

PUD:
where are the ulcers usually located in ZES?

simultaneous, recurrent gastric and duodenal ulcers (postbulbar)

42

46M alcoholic
hematemesis
PE: distended abdomen with splenomegaly, caput medusae, fluid wave
anicteric
spider angiomata on thorax
neuro exam unremarkable

Diagnosis?

Chronic Liver Disease with Portal Hypertension

43

MCC of liver cirrhosis

Portal hypertension

44

Chronic Liver Disease with Portal Hypertension:
pathology?

advanced liver cirrhosis complicated by portosystemic shunting

45

Chronic Liver Disease with Portal Hypertension:
most common causes?

alcoholism and viral hepatitis

46

Chronic Liver Disease with Portal Hypertension:
differentiate among common causes of this condition?

AST/ALT ratio >2 in alcoholic liver disease

AST/ALT ratio of 1 in viral hepatitis

47

Chronic Liver Disease with Portal Hypertension:
HP hallmarks seen in ALD compared to viral hepatitis?

Mallory bodies = ALD
Councilman bodies = Viral hepatitis

48

Chronic Liver Disease with Portal Hypertension:
three stages of ALD?

steatosis
hepatitis
cirrhosis

49

Chronic Liver Disease with Portal Hypertension:
other signs and symptoms
CLD?
PH?

CLD: palmar erythema, testicular atrophy, spider angioma, Dupytren contracture
PH: hemorrhoids, caput medusae, varices
(GUT, BUTT, and CAPUT)

50

Chronic Liver Disease with Portal Hypertension:
hematemesis?

ruptured esophageal varices

51

Chronic Liver Disease with Portal Hypertension:
gynecomastia? spider angiomata? palmar erythema?

due to high circulating estrogen levels

52

Chronic Liver Disease with Portal Hypertension:
Muehrche nails, peripheral edema, and prolonged bleeding time?

due to hypoalbuminemia, hypoproteinemia

53

Chronic Liver Disease with Portal Hypertension:
thrombocytopenia, anemia and leukopenia?

due to hypersplenism

54

Chronic Liver Disease with Portal Hypertension:
how to rule out other causes of ascites other than portal hypertension?

using serum ascites albumin gradient (SAAG)
SAAG >1.1 = portal hypertension
SAAG <1.1 = malignancy or infection

55

Chronic Liver Disease with Portal Hypertension:
most appropriate treatment?

TIPS procedure

56

Chronic Liver Disease with Portal Hypertension:
definitive treatment?

liver transplant

57

Chronic Liver Disease with Portal Hypertension:
complications if left untreated?

massive UGIB, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, bacterial peritonitis spontaneous

58

Chronic Liver Disease with Portal Hypertension:
responsible for fetor hepaticus?

musty fecal smell due to accumulation of mercaptans

59

Chronic Liver Disease with Portal Hypertension:
responsible for fetor hepaticus?

musty fecal smell due to accumulation of mercaptans

60

Chronic Liver Disease with Portal Hypertension:
treatment of hepatic encephalopathy

enemas
lactulose
protein restriction (branched chain amino acids, e.g. aminoleba)
neomycin

61

24F
recurrent abdominal pain and bloody diarrhea
unintentional weight loss
PE diffuse abdominal tenderness, and a rectal examination significant for frank blood
colon biopsy = crypt abscesses

Diagnosis?

IBD: Ulcerative Colitis

62

24F
recurrent abdominal pain and bloody diarrhea
unintentional weight loss
PE diffuse abdominal tenderness, and a rectal examination significant for frank blood
colon biopsy = crypt abscesses

Diagnosis?

IBD: Ulcerative Colitis

63

Ulcerative colitis: underlying pathology?

inflammatory bowel disease

64

IBD: types?

UC
and
CD

65

IBD:
differentiate UC and CD

UC: colon only, mucosal, lead pipe colon, pseudopolyps, crypt abscesses

CD: anywhere in GIT, with skip lesions and rectal sparing, transmural, cobblestone mucosa, noncaseating granulomas

66

IBD:
extracolonic manifestations associated?

arthritis
episcleritis
uveitis
pyoderma granulosum

67

IBD: Ulcerative Colitis
malignancy?

Colon cancer

68

IBD: Ulcerative Colitis
Bacterial infection that can cause flare ups?

Clostridium difficile

69

IBD: Ulcerative Colitis
DOC?

Sulfasalazine

70

IBD: UC complications?
Definitive treatment?

Exsanguination
Toxic megacolon
Definitive treatment is total colectomy