Gastroenterology Flashcards by Leisa Covington

Is FDA-approved for the treatment of opioid-induced constipation in adults with chronic non-cancer pain?

Oral naloxegol (Movantik) is a peripherally acting mμ-opioid receptor antagonist

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Patients with hepatitis B infection in the immune-tolerant phase (i.e phase with no hepatic inflammation & no fibrosis) require?

Serial monitoring of aminotransferase levels. No treatment

There are four typical phases of HBV infection: (1) immune tolerant, (2) immune active, (3) immune control (inactive), and (4) reactivation.

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Should you discontinue aspirin In patients with established cardiovascular disease who is about to undergo colonoscopy with polypectomy?

No, Aspirin should not be held before or after colonoscopy

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The most common cause of abnormal liver test results in the United States

Nonalcoholic fatty liver disease

Risk factors include obesity, diabetes mellitus, insulin resistance, hypertension, and hyperlipidemia. Alkaline phosphatase (ALP) levels may be slightly elevated as well, typically less than 2 to 2.5 times the upper limit of normal. The finding of a hyperechoic liver on ultrasonography is also consistent with NAFLD.

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Is caused by a tumor at the gastroesophageal junction infiltrating the myenteric plexus causing esophageal motor abnormalities; symptoms, barium-imaging and manometric findings, and endoscopic appearance are similar to achalasia

Pseudoachalasia

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Can reduce abdominal pain and bloating and improve stool consistency, frequency, and urgency in patients with diarrhea-predominant irritable bowel syndrome?

A low-FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, And Polyols) diet

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Patients with dysphagia associated with regurgitation of undigested food & halitosis should be evaluated with?

a barium esophagram for the presence of a Zenker diverticulum

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The diagnosis of hepatopulmonary syndrome is made by demonstrating an arterial oxygen tension less than 80 mm Hg (10.7 kPa) breathing ambient air, or an alveolar-arterial gradient of 15 mm Hg (2 kPa) or greater, along with evidence of intrapulmonary shunting on?

Echocardiography with agitated saline or macroaggregated albumin study

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Acalculous cholecystitis can present with biliary colic symptoms in the alert patient or with unexplained leukocytosis, sepsis, and jaundice in the critically ill patient. What’s the treatment?

Cholecystostomy tube placement

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In patients requiring NSAIDs, an evidence-based treatment strategy to prevent recurrent NSAID-induced peptic ulcers is the use of

A cyclooxygenase-2 selective NSAID plus a proton pump inhibitor

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Patients with small (<10 mm) hyperplastic polyps on baseline colonoscopic examination should undergo surveillance colonoscopy in?

10 years

Serrated polyps are classified into three histologic types: hyperplastic polyps, sessile serrated polyps, and traditional serrated adenomas. Hyperplastic polyps are the most common type of serrated polyp. They are non-neoplastic and are composed of normal mucosal elements; small hyperplastic polyps, often found in the rectosigmoid colon, are believed to have no clinical significance. As a result, the interval until the next screening examination is 10 years, the same as for patients who do not have polyps found on baseline examination. Sessile serrated polyps (also known as sessile serrated adenomas) and traditional serrated adenomas are both neoplastic and are precursors to colorectal cancer; they should be completely excised.

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Patients who have cholangitis with evidence of biliary obstruction should be treated with antibiotic therapy and biliary decompression with

Endoscopic retrograde cholangiopancreatography (ERCP)

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Esophageal stricture in patients with eosinophilic esophagitis requires treatment with?

Endoscopic dilation when symptoms do not respond to medical therapy (swallowed aerosolized fluticasone).

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Toxic megacolon is defined by the presence of toxicity and evidence of colonic dilation; it requires

Prompt surgical treatment

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Is a cause of nonbloody, watery diarrhea in older adults and is diagnosed by colonoscopy with random biopsies from multiple colonic segments.

Microscopic colitis

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Almost all patients (>90%) with autoimmune pancreatitis enter clinical remission in response to?

Glucocorticoids

Note: typical symptom of painless jaundice & the characteristic “sausage-shaped” pancreas on imaging, the patient has type 1 autoimmune pancreatitis, a frequent manifestation of IgG4 disease. He also has associated IgG4-related conditions, sialadenitis, and probable retroperitoneal fibrosis.

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Upon recognition of acute fatty liver of pregnancy?

The fetus should be delivered immediately

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The finding of a gallbladder polyp larger than 1 cm in size, or a polyp of any size associated with gallstones, is an indication for

Cholecystectomy even if the patient is asymptomatic

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After eradication therapy, consisting of amoxicillin, clarithromycin, and omeprazole, for Helicobacter pylori infection,

Eradication should be confirmed using the urea breath test or fecal antigen test.

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For patients with mild gallstone pancreatitis, treatment should include

Same-admission cholecystectomy reduces rates of gallstone-related complications compared with cholecystectomy after hospital discharge

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Indications for endoscopic retrograde cholangiopancreatography in patients with primary sclerosing cholangitis are:

bacterial cholangitis (presents with fever, rigors, right-upper-quadrant pain, and leukocytosis). increasing jaundice, increasing pruritus, or a dominant stricture on imaging

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Red-flag symptoms such as rectal bleeding with iron deficiency anemia, abdominal pain, and weight loss should prompt evaluation by

colonoscopy for colorectal cancer regardless of the patient’s age or the presence of bleeding hemorrhoids

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Is a centrally mediated disorder of gastrointestinal pain characterized by a paradoxical increase in abdominal pain with increasing doses of opioids

Narcotic bowel syndrome, also known as opiate-induced gastrointestinal hyperalgesia

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Treatment of chronic pancreatitis–related persistent pain should proceed in a stepwise approach beginning with

lifestyle modifications (discontinue alcohol and cigarettes) and the use of simple analgesics (acetaminophen, NSAIDs)

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Mild hepatitis B virus–related polyarteritis nodosa is treated with

Antiviral agents e.g. Entecavir Note: Sofosbuvir and ledipasvir are direct-acting antiviral agents used to treat hepatitis C virus (HCV) infection

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ is preferred in patients with acute pancreatitis because of the benefit of maintaining a healthy gut mucosal barrier to prevent translocation of bacteria.

Enteral Nutrition

Is indicated for patients at high risk for the development of spontaneous bacterial peritonitis, including patients with very low ascitic-fluid protein levels and those with advanced liver failure?

Primary prophylactic antibiotic therapy e.g. Cipro

Rapid gastric emptying of hyperosmolar chyme into the small intestine after partial gastric resection can lead to postprandial vasomotor symptoms, abdominal pain, and diarrhea, collectively known as

Dumping syndrome

Treatment of chronic idiopathic constipation in adults with symptoms refractory to first-line therapies?

Linaclotide (Linzess) is a peripherally acting guanylate cyclase-C receptor agonist

Pregnant women who have hepatitis B virus DNA levels greater than 200,000 IU/mL at 24 to 28 weeks' gestation should be treated with?

Tenofovir or Lamivudine or Telbivudine to prevent vertical transmission during delivery. Tenofovir is preferred over telbivudine and lamivudine due to lower rates of resistance. Note: Pegylated interferon is not considered safe in pregnancy and, therefore, would be an inappropriate choice for this patient.

This must be considered as a cause of acute pancreatitis in patients older than age 40 years when no other cause has been identified and/or when worrisome features, such as weight loss or new onset of diabetes mellitus, are present?

Pancreatic neoplasm **_CT abdomen w/ contrast_** can help with diagnosis

Once endoscopic hemostasis has been achieved in a patient with gastrointestinal bleeding, anticoagulation should be

Anticoagulation e.g Warfarin should be reinitiated now, and in most cases, this can be done on the same day as the procedure

Best screening test for celiac disease?

Anti–tissue transglutaminase (tTG) IgA antibody testing

After treatment of colon cancer, patients should undergo surveillance colonoscopy

1 year after diagnosis

What is the best management option for high-risk cystic lesions of the pancreas, such as intraductal papillary mucinous neoplasms that involve the main duct

Surgical resection

Hematochezia associated with hemodynamic instability in a young patient is likely due to an upper gastrointestinal source & should be diagnosed with?

EGD

Patients with this type of diarrhea may pass liters of stool daily, causing severe dehydration and electrolyte disturbances, with persistent stooling despite fasting?

Secretory diarrhea

Colonoscopy results in Crohn disease show patchy distribution of mucosal inflammatory changes with “skip areas” of normal intervening mucosa, and biopsy results for involved mucosa show features of chronicity

distorted and branching colonic crypts

Patients with uncomplicated diverticulitis should undergo colonoscopy when?

1 to 2 months after the episode of acute diverticulitis, when colonic inflammation has resolved

Patients with newly diagnosed pernicious anemia should be evaluated for gastric adenocarcinoma and gastric carcinoid with

Upper endoscopy and gastric biopsy

The most effective treatment approach for anal fissure is?

daily warm-water sitz baths and the use of the bulk laxative psyllium

Patients with multiple fundic gland polyps found at a young age should be evaluated for

Familial adenomatous polyposis (FAP) with a **_colonoscopy_**

Approximately 5% of patients with inflammatory bowel disease will develop _______________________ during the course of their disease, typically presenting as cholestatic liver injury with a characteristic imaging study showing bile duct strictures and dilations (“string of beads”)

Primary sclerosing cholangitis

Patients with a clinical diagnosis of gastroesophageal reflux disease should start

An empiric trial of a proton pump inhibitor in conjunction with lifestyle and dietary changes, with no further testing

Patients with cirrhosis are at increased risk for the development of osteoporosis and should be screened using

Bone densitometry (DEXA scan)

All hospitalized patients with inflammatory bowel disease should be given pharmacologic venous thromboembolism prophylaxis with

subcutaneous heparin

Patients with a family history suggesting Lynch syndrome (three family members are affected with a Lynch syndrome–associated cancer, at least two successive generations are affected, one of the affected family members is a first-degree relative of the other two affected family members, and at least one cancer was diagnosed in a family member younger than age 50 years) should be referred for

Genetic counseling

Can be a helpful diagnostic test in patients with suspected extraesophageal manifestations of gastroesophageal reflux disease?

Ambulatory pH testing

Medications that decrease kidney perfusion should be discontinued in patients with ascites & those medications are:

NSAIDs, ACE inhibitors, and angiotensin receptor blockers (ARBs) Note: Propranolol and other nonselective β-blockers are often used prophylactically for the prevention of variceal hemorrhage, but they do not have a role in ascites. Furthermore, in some patients with ascites that is refractory to medical management, β-blockers may worsen clinical outcomes, including survival.

Acute liver failure is an indication for

immediate referral to a **_liver transplantation_** center

In mild to moderately active ulcerative colitis compared with

Combined mesalamine therapy (oral and enema) is superior for induction of remission compared with these therapies alone

Patients younger than age 60 years presenting with dyspepsia (i.e. epigastric pain) should first undergo:

a noninvasive test for *Helicobacter pylori* followed by eradication therapy if testing is positive

The mainstay of therapy for amebic liver abscesses is

antibiotic therapy, such as **_metronidazole, plus a luminal agent, such as paromomycin_**, to eradicate the coexisting intestinal infection

Chronic bloody diarrhea and abdominal discomfort are typical presenting symptoms of IBD. The endoscopic description of inflammation beginning at the anorectal verge and extending proximally in a continuous fashion with transition to normal mucosa at splenic flexure is consistent with

left-sided ulcerative colitis

This condition should be considered in _all patients younger than age 40 years who have unexplained liver disease_?

**_Wilson disease_**. Diagnosed with a low serum ceruloplasmin. Slit-lamp examination of the cornea can be performed to evaluate for Kayser-Fleischer rings, which most commonly occur in patients with neurologic manifestations of Wilson disease.

Patients with achalasia who are at high surgical risk should be treated with

botulinum toxin injection

In patients with atypical chest pain, a ______________ must be ruled out before starting treatment for gastroesophageal reflux disease.

Cardiac cause with EKG

Is characterized by multiple clinical or biochemical relapses of jaundice & elevated LFTs with spontaneous improvement within months to 1 year without intervention.

The relapsing, remitting variant of hepatitis A viral infection

Long-term proton pump inhibitor (PPI) therapy for uncomplicated GERD should be given at the lowest effective dose possible, and consideration should be given to

reducing or stopping PPI therapy at least once a year.

The mainstay of therapy for intrahepatic cholestasis of pregnancy is

Ursodeoxycholic acid, which is associated with alleviated symptoms and improved liver test abnormalities.

Isolated right-colon ischemia may be a warning sign of acute mesenteric ischemia caused by embolism or thrombosis of the superior mesenteric artery and should be evaluated using

CT angiography

Causes medication-induced enteropathy that can mimic refractory celiac disease with upper endoscopy with duodenal biopsies showing villous flattening & increased intraepithelial lymphocytes?

Olmesartan

Barrett esophagus with low-grade dysplasia should be treated with

Endoscopic ablation therapy in patients without significant comorbidities

is a common parasitic infection that causes watery diarrhea occurs most often among children, child care workers, and backpackers or campers who drink untreated water from lakes, rivers, or wells.

*Giardia lamblia* infection

The diagnosis of gastroparesis requires the presence of specific symptoms, absence of mechanical outlet obstruction, and objective evidence of delay in gastric emptying into the duodenum. Diagnosis is made with a ?

Gastric emptying scintigraphy & must be made before treatment with metoclopramide and domperidone

The mainstay of therapy for variceal hemorrhage is endoscopic therapy, and adjunctive therapies such as

Antibiotic therapy improve outcomes

Up to 80% of patients with hepatic encephalopathy have a precipitating factor, most commonly infection or gastrointestinal bleeding. Also, in a patient with recently started benzodiapines, this should be?

Discontinued Note: Lactulose is first-line treatment and should be titrated to produce three stools per day. Rifaximin is added to lactulose for prevention of recurrent episodes after a second episode of hepatic encephalopathy. Due to its expense, it is not a first-line therapy for hepatic encephalopathy.

Individuals with a first-degree relative with colon cancer or an advanced adenoma diagnosed at an age younger than 60 years, or two or more first-degree relatives with colon cancer or advanced adenoma diagnosed at any age, should begin colon cancer screening at age

40 years (or 10 years earlier than the youngest age at which colon cancer was diagnosed in a first-degree relative, whichever is first)

Patients with cirrhosis and who meet the Milan criteria (up to three hepatocellular carcinoma tumors ≤3 cm or one tumor ≤5 cm) are best treated with

**_Liver transplantation_** and have excellent 5-year survival rates. Note: Biopsy of the lesion is not indicated as a lesion \>1 cm with contrast enhancement in the arterial phase & portal venous washout meets radiologic criteria for hepatocellular carcinoma &, therefore, does not require a biopsy. Surgical resection would be dangerous for this patient, given the evidence of portal hypertension, which confers increased risk for intraoperative bleeding as well as risk for postoperative liver failure.

Typically presents in young men with symptoms of dysphagia and in patients with a history of food allergies, eczema, and asthma

Eosinophilic esophagitis

Incidentally found gallstones with no associated symptoms and no complications require

No further intervention

Gastrointestinal bleeding occurring in patients following aortic graft surgery should raise the possibility of aortoenteric fistula. The patient presents with the classic “herald bleed” of aortoenteric fistula: a brisk bleed associated with hypotension that stops spontaneously and then is followed later by massive gastrointestinal hemorrhage. How do you diagnosed?

CT with contrast is the initial test in appropriate patients.

Is the recommended initial diagnostic test after hemodynamic resuscitation in most patients with significant lower gastrointestinal bleeding

Colonoscopy within 24 hours with adequate bowel preparation.

Patients with uncomplicated diverticulitis should be treated

conservatively with oral antibiotics

Patients whose Barrett esophagus is indefinite for dysplasia should begin

Optimized antisecretory medical therapy and undergo a repeat endoscopy

Fecal loading (excess stool in the colon) with resultant overflow diarrhea is a common cause of fecal incontinence in elderly patients, particularly those who are hospitalized or have degenerative neurologic disorders. Diagnosis is made with?

Abdominal X-ray

Is a low-flow state of the colon occurring most frequently in the left colon and characterized by moderate, left-sided, cramping abdominal pain followed by bloody diarrhea?

Ischemic colitis

Are effective in inducing and maintaining remission in moderate to severe Crohn disease

Anti–tumor necrosis factor agents such as infliximab

Patients with Lynch syndrome should begin screening colonoscopy between

ages 20 and 25 years or 2 to 5 years before the earliest age of colorectal cancer diagnosis in the family, whichever comes first, and colonoscopy should be repeated every 1 to 2 years if the baseline examination is normal.

A history of multiple family members with gastric cancer, particularly before age 50 years, or multiple family members with lobular breast cancer with or without gastric cancer, suggest the possibility of hereditary diffuse gastric cancer and the need for

Upper endoscopy and testing for mutations of the *CDH1* gene.

In patients with well-preserved liver function, drug-induced liver injury should be managed with discontinuation of the offending medication and

observation until resolution of symptoms occurs

Centrally mediated abdominal pain syndrome is characterized by near-constant abdominal pain lasting longer than 6 months, involving a large anatomic distribution, and without initiating triggers or alarm features. What's the treatment?

Cognitive-behavioral therapy

In patients with upper gastrointestinal bleeding, a restrictive transfusion strategy (transfusion threshold of less than 7 g/dL [70 g/L] with a target hemoglobin level of 7-9 g/dL [70-90 g/L]) is associated with decreased mortality, length of hospital stay, and transfusion-related adverse events compared to a

liberal transfusion strategy, which includes not transfusing unit Hgb is \<7 or \<8 in a hemodynamically unstable patient.

In patients with familial adenomatous polyposis should begin at onset of colonic polyposis or at age 25 to 30 years, whichever comes first?

Screening should involved upper-endoscopy screening for duodenal cancer

Patients with three or more adenomas on screening colonoscopy should undergo surveillance colonoscopy in

in 3-5 years

First-line treatment for functional dyspepsia (chronic burning epigastric pain that subsides with eating) is once-daily omeprazole for at least 4 weeks; if symptoms do not respond, a

Tricyclic antidepressant is the next recommended treatment.

Mixed cryoglobulinemia arising from chronic hepatitis C viral infection resolves after treatment and eradication of the virus. How should you treat?

Ledipasivir & Sofosbuvir Note: Pegylated interferon and ribavirin are no longer recommended for treatment of HCV infection due to adverse effects & lower efficacy compared to interferon-free, direct-acting antiviral therapy.

The first step in the management of microscopic colitis is to discontinue a potentially causative medication, after which supportive treatment with antidiarrheal agents such loperamide can be tried & for patient's that don't respond _____________ is recommended.

Budesonide Note: Because budesonide is expensive, alternative treatments such as bismuth salicylate may be considered if cost is a determining factor. Prednisone should not be used as first-line treatment of microscopic colitis because of its unfavorable side effects.

For women with asymptomatic hepatic adenomas smaller than 5 cm in size,

Estrogen-containing oral contraceptive agents should be discontinued, and follow-up liver imaging is recommended every 6 months for at least 2 years. Note: Hepatic adenomas may also be associated with anabolic-steroid use, obesity, and the metabolic syndrome.

Is the most appropriate test to evaluate patients for causes of small-bowel bleeding after negative upper endoscopy and colonoscopy.

Capsule endoscopy Note: Capsule endoscopy is contraindicated in patients with gastroparesis, swallowing difficulty, and partial bowel obstructions, and in any patient who cannot undergo follow-up surgery.

Chronic hepatitis B viral infection in the immune-active, hepatitis B e antigen–positive phase should be treated with?

Tenofovir or entecavir to decrease hepatic inflammation and the risk for progression to fibrosis. Note: Adefovir and lamivudine are not preferred antiviral agents given the risk for HBV resistance.

Is a first-line treatment for patients whose symptoms meet the criteria for IBS with predominant constipation?

Polyethylene glycol 3350 (Miralax)

For *Helicobacter pylori* infection that persists after eradication therapy, the salvage therapy regimen should consist of

Bismuth, metronidazole, omeprazole, and tetracycline for 14 days

This condition is characterized by the development of oliguric kidney failure, bland urine sediment, and marked sodium retention (edema, ascites, low urinary sodium), in patients with end-stage liver disease and portal hypertension

Hepatorenal syndrome

Asymptomatic patients with walled-off necrosis of the pancreas require

No intervention

Patients with hepatitis C viral infection who achieve sustained virologic response have a reduced risk for hepatocellular carcinoma; regardless of virologic response,

Ultrasonographic surveillance every 6 months is recommended for patients with stage 3 or stage 4 fibrosis.

Gastroenterology Flashcards

(96 cards)