Gastroenterology

Question 1

Anti smooth muscle Ab is an indicator of_____

Answer 1

Autoimmune hepatitis

Question 2

The diagnostic criteria for________ are esophageal symptoms (dysphagia), esophageal biopsies showing 15 eosinophils/hpf or greater, and exclusion of other causes of esophageal eosinophilia

Answer 2

eosinophilic esophagitis

Question 3

Treatment of opiate induced constipation_____

Answer 3

oral naldemedine or subcutaneous methylnaltrexone, and naloxegol, a pegylated form of naloxone.

Question 4

The diagnosis of ______ can be established without a liver biopsy in patients with an alkaline phosphatase level elevated more than 1.5 times the upper limit of normal and positive results on testing for antimitochondrial, sp100, or gp210 antibodies.

Answer 4

PBC

Question 5

______ should be considered when undigested food is brought up several hours after a meal or if a patient reports hearing a gurgling noise in the chest.

Answer 5

A pharyngoesophageal (Zenker) diverticulum

Question 6

Initial study for dysphagia_____

Answer 6

Barium swallow

*dysphagia to liquids alone, think motility disorder rather than physical obstruction

Question 7

When to do esophageal manometry ______

Answer 7

Esophageal manometry has limited value in diagnosing GERD, but should be considered as part of the evaluation for antireflux surgery to rule out motility disorders such as achalasia.

Patients should undergo objective testing, such as impedance-pH monitoring, to confirm true acid reflux and correlation with symptoms before surgery.

Question 8

For GERD, PPI trial is ________

Answer 8

8 weeks, 30 minutes before meals

Question 9

The diagnostic criteria for EoE are esophageal symptoms (dysphagia), esophageal biopsies showing ____ eosinophils/hpf or greater, and exclusion of other causes of eosinophilia.

Answer 9

15

Question 10

Common causes of Pill esophagitis______

Answer 10

alendronate, ferrous sulfate, NSAIDs, and potassium chloride.

Question 11

Treatments of achalasia

Answer 11

Endoscopic therapy involves injection of botulinum toxin, pneumatic dilation, or peroral endoscopic myotomy

Medical therapy is reserved for patients who are poor candidates for endoscopic or surgical therapy. LES pressure can be reduced with medical therapy, including calcium channel blockers (nifedipine) or long-acting nitrates.

Achalasia>10 years, may decide on EGD for screening SCC of esophagus

Question 12

Treatment for DES (Diffuse esophageal spasm)

Answer 12

Medical therapy with antidepressants (trazadone and imipramine) or a phosphodiesterase inhibitor (sildenafil) can relieve chest pain. Dysphagia may respond to calcium channel blockers. Botulinum toxin injection has been reported to alleviate dysphagia symptoms.

“Nutcracker” or “jackhammer” esophagus is found in patients with high-amplitude peristaltic contractions of greater than 220 mm Hg.

Question 13

Disease associated with hypotonic esophagus _____

Answer 13

CREST/Schleroderma

Question 14

No clear barrett’s surveillance guidelines,

Men older than age 50 years with GERD symptoms for more than 5 years and additional risk factors (nocturnal reflux symptoms, hiatal hernia, elevated BMI, intra-abdominal distribution of body fat, tobacco use) may benefit from screening endoscopy.

Question 15

Barretts guidelines

1) No dysplasia: EGD q5years

2) Indeterminate: PPI, repeat endoscopy in 6 months

3) Low grade dysplasia: BID PPI, EGD q6months, endoscopic resection of visible lesions

4) High grade dysplasia: Endoscopic resection

Question 16

Treatment of functional abdominal pain ________

Answer 16

First-line treatment for functional dyspepsia is once-daily omeprazole for at least 4 weeks; if symptoms do not respond, a tricyclic antidepressant is the next recommended treatment

Question 17

For patients with dyspepsia, routine upper endoscopy to exclude malignancy is reserved for patients older than age _____ years.

Answer 17

60

Question 18

bleeding PUD related to low-dose aspirin use for secondary cardiovascular prevention, aspirin should be restarted 1 to 7 days after cessation of bleeding

Answer 18

if aspirin cannot be stopped, PPI day

Question 19

PPI therapy can be discontinued after confirmation of H. pylori eradication in patients with H. pylori–associated bleeding PUD.

Question 20

Serologic testing is most useful as an adjunct test in patients with bleeding PUD because of the decreased sensitivity of biopsy in the setting of acute bleeding. Any upper endoscopy for the evaluation of dyspepsia, or with the finding of gastric erosions or ulcers, should include gastric biopsies for H. pylori testing by histology or a rapid urea test.

Question 21

Atrophic gastritis can cause deficiency in _____

Answer 21

B12 (Pernicious anemia), Iron,

Question 22

Gastric intestinal metaplasia

Answer 22

Endoscopic surveillance should be considered in patients at increased risk (such as those with complete or extensive gastric intestinal metaplasia on endoscopy; those with a family history of gastric cancer; racial/ethnic minorities; or those who have emigrated from East Asia, Russia, or South America).

Question 23

____ is the most common cause of lymphocytic gastritis. Other causes include HIV infection, Crohn disease, common variable immunodeficiency, and, rarely, H. pylori infection.

Answer 23

Celiac disease,

nodules in prominent rugal folds

Question 24

_______ may be used instead of PPIs in patients with intolerance or unwillingness to take PPIs for aspirin induced PUD/Gastritis

Answer 24

Misoprostol

Question 25

Causes of gastroparesis____

Answer 25

DM2, Schleroderma, Amyloid, mesenteric ischemia, hypothyroid, Parkinsons, idiopathic

Question 26

Gastroparesis diagnosis 1) EGD : rule out physical obstruction 2) Gastric Emptying Study

Answer 26

Tx: Reglan, mirtazapine, amytryptiline (TCA)

Question 27

Hyperplastic stomach polyps____

Answer 27

basically always resect

Question 28

Adenoma in the stomach associated with _____

Answer 28

Lynch syndrome, warrants EGD surveillance 1 year after

Question 29

GIST management

Answer 29

Treatment consists of surgical excision if the GIST is symptomatic or high-risk features are present. For GISTs without high-risk features, yearly endoscopic surveillance is indicated.

Question 30

Carcinoid tumors in stomach associated with_____

Answer 30

Zollinger Ellison gastrin secreting tumor, which in turn is associated with MEN 1

Question 31

If intestinal metaplasia with high-grade dysplasia is identified, it should be resected because 25% of cases progress to adenocarcinoma

Question 32

Dumping syndrome

Answer 32

First-line treatment for dumping syndrome is dietary, with smaller, more frequent meals and ingestion of liquids after meals. Decreasing carbohydrate intake, especially simple carbohydrates, and increasing protein and fiber intake may also alleviate symptoms. Acarbose, an α-glycosidase hydrolase inhibitor that interferes with the digestion of polysaccharides to monosaccharides, can be used for late symptoms of dumping syndrom

Question 33

Drugs associated with pancreatitis______

Answer 33

6MP, simvastatin, HCTZ, Lasix, mesalamine

Question 34

New imaging modality for chronic pancreatitis_____

Answer 34

secretin-enhanced magnetic resonance cholangiopancreatography may be useful as second- and third-line tests

Question 35

Most durable treatment for chronic pancreatitis______

Answer 35

Surgery offers the best long-term results for chronic, refractory pain management and, depending on anatomy and cause, may include lateral pancreaticojejunostomy, duodenal-preserving pancreatic head resection, pancreaticoduodenectomy, distal pancreatectomy, or even total pancreatectomy with or without auto–islet cell transplantation

Question 36

Auto-immune pancreatitis (IgG4 disease for Type 1)

Answer 36

Diagnosis of autoimmune pancreatitis requires the presence of a narrowed main pancreatic duct and parenchymal swelling (“sausage-shaped” pancreas) on imaging and disease response to glucocorticoids.

Question 37

At least 50% of patients with familial adenomatous polyposis syndrome develop adenomatous changes of the periampullary region; upper endoscopy screening in patients with this syndrome should begin at age 25 to 30 years.

Question 38

An osmotic gap of less than 50 mOsm/kg (50 mmol/kg) suggests secretory diarrhea, and a gap greater than 100 mOsm/kg (100 mmol/kg) suggests osmotic diarrhea.

Answer 38

Secretory diarrhea = Celiac/tropical sprue, Whipple disease, MALT, infection, bile acid malabsorption, hyperthyroid (infection/inflammation is the theme) Osmotic: lactose

Question 39

Celiac: If clinical suspicion is high and initial testing is negative, additional testing should be pursued. Antibody testing is less reliable if the patient is on a gluten-free diet. In such patients, genetic testing for HLA-DQ2 or HLA-DQ8 should be considered

Answer 39

Assessment of bone density and assessment for possible nutritional deficiencies (vitamin B12, vitamin D, iron, folate) at the time of diagnosis should be considered to ensure adequate bone health.

Question 40

___________ can cause a celiac like condition, its a medication

Answer 40

Olmesartan, Tx: gluten free diet

Question 41

SIBO diagnosis

Answer 41

Glucose and lactulose breath tests have acceptable specificity (around 80%) but poor sensitivity (30%-40%) for diagnosing SIBO. Gold standard = jejunal aspirate Hydrogen breath test

Question 42

Glucagon-like peptide 2 and its analog, teduglutide, are new pharmacologic agents for treatment of short bowel syndrome. Both have been evaluated in randomized trials and found to increase intestinal wet weight absorption and decrease parenteral fluid support in patients with short bowel syndrome.

Answer 42

Caution to B12 deficiency

Question 43

Fecal calprotectin should be considered to help differentiate IBD from irritable bowel syndrome

Question 44

The earliest endoscopic findings of Crohn disease include aphthous ulcers, which can coalesce to form stellate ulcers, and a “cobblestone” mucosal appearance. A characteristic mucosal feature of Crohn disease is the so-called “skip lesion,

Answer 44

It is important that all hospitalized patients with IBD be given venous thromboembolism prophylaxis with subcutaneous heparin

Question 45

Methotrexate is an immunomodulator that should be considered for use in alleviating signs and symptoms in patients with steroid-dependent Crohn disease and for maintaining remission. It is not effective in ulcerative colitis.

Question 46

If latent tuberculosis is present, treatment with isoniazid should occur for at least 2 months before initiation of anti-TNF therapy. Patients should also be assessed for chronic hepatitis B viral infection before starting anti-TNF therapy and receive treatment if needed.

Question 47

The combination of infliximab and antibiotics is more effective than infliximab alone for perianal fistula.

Question 48

Live vaccines such as measles, mumps, rubella; varicella; and herpes zoster are contraindicated in immunosuppressed patients with IBD.

Question 49

In patients with IBD (ulcerative colitis with disease proximal to the sigmoid colon and Crohn disease with more than one third of the colon involved), surveillance colonoscopy should begin 8 years after diagnosis and recur every 1 to 2 years thereafter. Primary sclerosing cholangitis increases the risk for colorectal cancer, and surveillance colonoscopy should begin at the time of diagnosis and recur yearly thereafter.

Question 50

Treatment of Microscopic colitis

Answer 50

First-line treatments include supportive treatment with antidiarrheal agents such loperamide or bismuth subsalicylate. The next step is oral budesonide, which is efficacious but has a high rate of recurrent symptoms when discontinued.

Question 51

IBS-C Treatment

Answer 51

The evidence for treatment efficacy is strongest for polyethylene glycol, lubiprostone, and linaclotide

Question 52

IBS-D Treatment

Answer 52

Prescription medications with FDA approval for the treatment of IBS–D include rifaximin, eluxadoline, and alosetron Eluxadoline (combination of a µ-opioid receptor agonist and a δ-opioid receptor antagonist)

Question 53

___________, also known as opiate-induced gastrointestinal hyperalgesia, is a centrally mediated disorder of gastrointestinal pain characterized by a paradoxical increase in abdominal pain with increasing doses of opioids.

Answer 53

Narcotic bowel syndrome

Question 54

Treatment of complicated diverticulitis depends on the severity of illness and CT findings. If the CT scan shows a large (>5 cm) abscess, CT-guided drainage may be needed. Surgery is indicated for patients presenting with, or who develop, peritonitis or persistent sepsis.

Question 55

Treatment for chronic mesenteric ischemia

Answer 55

CMI is treated with percutaneous endovascular stenting or surgical revascularization. Choice of therapy depends on operative risk and occlusive lesion characteristics

Question 56

Thrombosed external hemorrhoids are best treated with surgical excision within 72 hours of symptom onset. Surgical hemorrhoidectomy should be reserved for refractory hemorrhoids, large external hemorrhoids, or combined internal and external hemorrhoids with rectal prolapse.

Question 57

The U.S. Preventive Services Task Force recommends the use of low-dose aspirin for preventing colorectal cancer and cardiovascular disease in individuals aged 50 to 59 years who are at increased risk for cardiovascular disease.

Question 58

Colon cancer screening 1)First degree <60, screen at 40 or 10 years earlier OR multiple first degree at any age, repeat every 5 years 2) FAP (auto-dominant, tumor suppressor gene): Age 10-12 q1-2 years until colectomy 3) Lynch (auto-dominant, mis-match repair gene): Age 20-25, or 10 years younger, q1-2 years

Answer 58

Lynch -Screening with upper endoscopy for stomach and small-bowel cancers can be considered starting at age 30 to 35 years and repeated every 2 to 5 years

Question 59

There are three primary syndromes associated with hamartomas in the gastrointestinal tract: juvenile polyposis syndrome (JPS), Peutz-Jeghers syndrome (PJS), and PTEN hamartoma syndrome, also known as Cowden syndrome.

Answer 59

PJS hamartomas are found primarily in the small bowel but can also develop in the stomach and colon (Figure 28). PJS is also characterized by hyperpigmented mucocutaneous macules on the lips and buccal mucosa - Small bowel hamartomas

Question 60

Definition of inactive HepB

Answer 60

To be considered inactive, the ALT level must be normal and the HBV DNA level must be 2000 IU/mL or lower when measured every 3 to 4 months for 1 year. Prophylactic oral antiviral therapy should be given to patients who are HBsAg-positive or isolated core antibody–positive and receiving B-cell depleting therapy (for example, rituximab, or ofatumumab), prednisone (≥10 mg/d for at least 4 weeks), or anthracycline derivatives. Patients undergoing therapy with tumor necrosis factor-α or tyrosine kinase inhibitors should be considered for prophylaxis.

Question 61

Hep B Treatment

Answer 61

First-line treatment is entecavir or tenofovir. Lamivudine, adefovir, and telbivudine are less commonly used due to resistance. Pegylated interferon can be used for 48 weeks in patients with high ALT levels, low HBV DNA levels, and without cirrhosis. Candidates for interferon are those who have a desire for finite therapy, are not pregnant, and do not have significant psychiatric disease, cardiac disease, seizure disorder, cytopenia, or autoimmune disease.

Question 62

HBV associated with

Answer 62

HBV infection develop membranous nephropathy, membranoproliferative nephropathy, polyarteritis nodosa or cryoglobulinemia

Question 63

HCV cure

Answer 63

Cure is defined by the absence of HCV RNA in blood 12 weeks after completion of treatment. HCV antibodies remain positive indefinitely and should not be rechecked.

Question 64

Who to start Hep B treatment:

Answer 64

Treatment is generally indicated in chronic hepatitis B patients with HBV DNA >2000 IU/mL, elevated ALT and/or at least moderate histological lesions, while all patients with cirrhosis and detectable HBV DNA should be treated.

Question 65

Patients with stage F3 fibrosis or cirrhosis require ongoing surveillance for hepatocellular carcinoma even after virologic cure

Question 66

Hepatitis D treatment

Answer 66

Patients infected with HDV with evidence of progressive liver disease should receive treatment with pegylated interferon for 12 months; cure rates are 25% to 45%.

Question 67

autoimmune hepatitis

Answer 67

Duration of treatment should be 2 to 3 years before consideration of withdrawal. A liver biopsy is recommended to determine histologic response before consideration of drug withdrawal

Question 68

Common drugs associated with liver injury:

Answer 68

Acetaminophen, antibiotics (particularly amoxicillin-clavulanate), and antiepileptic agents (phenytoin and valproate)

Question 69

Hemachromatosis

Answer 69

Elevated transferrin saturation and elevated serum ferritin levels can suggest a diagnosis of hereditary hemochromatosis; transferrin saturation is recommended as the initial diagnostic test. serum ferritin level greater than 1000 ng/mL (1000 µg/L).

Question 70

Treatment of wilsons disease______

Answer 70

Trientine is preferred over penicillamine due to a lower rate of adverse effects. Zinc supplements can be administered to decrease the intestinal absorption of copper.

Question 71

Diagnosis of PBC_____

Answer 71

Diagnosis does not require liver biopsy when the ALP is at least 1.5 times the upper limit of normal and antimitochondrial antibody testing is positive, or when other PBC-specific autoantibodies, including sp100 or gp210, are present if antimitochondrial antibody testing is negative. The initial treatment is ursodeoxycholic acid. Response to treatment is defined by improvement of ALP level to less than 1.67 times the upper limit of normal.

Question 72

All patients with PSC and without known IBD should have a colonoscopy at the time of PSC diagnosis

Answer 72

Diagnosis via MRCP/ERCP and clinical presentation PSC often requires liver transplantation and has the highest case-based mortality rate among the autoimmune liver diseases. 15% lifetime risk for cholangiocarcinoma and also have an increased risk for gallbladder cancer. Surveillance for cholangiocarcinoma with CA 19-9 and ultrasonography or, preferably, MRCP should be completed every 6 to 12 months.

Question 73

Varices in patients with cirrhosis

Answer 73

No varices: EGD q 3 years Small: EGD q 2 years, unless b blocker started?

Question 74

_________ are associated with oral contraception use and occur eight times more frequently in women than in men

Answer 74

Hepatic adenomas Cancer risk higher when >5cm Hepatic adenomas 5 cm in size or smaller can be managed with serial imaging every 6 months for a 2-year period. For patients with hepatic adenomas larger than 5 cm in size, the risk for hemorrhage or malignant transformation is elevated and surgical resection should be considered.

Question 75

HCC Treatment

Answer 75

Sorafenib is used for advanced hepatocellular carcinoma, which includes cases with macrovascular invasion or extrahepatic spread. In 2017, the FDA approved two drugs for second-line therapy: regorafenib, an oral multi-kinase inhibitor, and nivolumab, an intravenous humanized monoclonal antibody against the programmed cell death receptor. Goal is to make transplant candidate, ,3cm 3 lesions, 1 lesion 5 cm (Milan criteria_

Question 76

Hep B During Pregnancy

Answer 76

Oral antiviral agents approved in pregnancy include lamivudine, telbivudine, and tenofovir. Breastfeeding is not contraindicated during treatment. Passive immunization with HBV immune globulin and active HBV vaccination should be administered to newborns within 12 hours of delivery Trimester 2/3, you can treat women with anti-virals

Question 77

HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelets) syndrome is a severe complication of preeclampsia. HELLP typically presents with nonspecific symptoms such as abdominal pain, nausea with vomiting, pruritus, and jaundice.

Answer 77

Acute fatty liver of pregnancy is a potential cause of acute liver failure. Affected patients may require transfer to a liver transplant center. Prompt delivery of the fetus once the diagnosis is recognized typically results in improvement of the mother's medical condition within 48 to 72 hours

Question 78

Budd Chiari (Hepatic Vein Thrombosis)

Answer 78

The classic presentation of Budd-Chiari syndrome includes hepatomegaly, ascites, and right-upper-quadrant abdominal pain Long-term anticoagulation is required in patients with Budd-Chiari syndrome, although bleeding risks are significant in patients with acute or chronic liver disease, portal hypertension, and esophageal varices. Angioplasty of the hepatic veins and/or TIPS placement can be used to reestablish adequate hepatic venous drainage

Question 79

The most common stones = cholesterol Black pigment stones, usually composed of calcium bilirubinate, can form in patients with chronic hemolytic disease states, ineffective erythropoiesis, ileal disease such as Crohn disease, and cirrhosis. Brown pigment stones are composed of unconjugated bilirubin and varying amounts of other substances, such as cholesterol, but also contain bacteria. These are typically found in patients with biliary stasis and bacterial biliary infection,

Question 80

Gallbladder Polyp: 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.

Question 81

Hilar cholangiocarcinoma: Patients with unresectable hilar cholangiocarcinoma smaller than 3 cm in size and without extrahepatic spread can be evaluated for liver transplantation at select centers with neoadjuvant chemoradiation protocols. However, percutaneous or transluminal biopsy of hilar cholangiocarcinoma excludes a patient for liver transplantation due to the risk for tumor seeding.

Question 82

Heyde Syndrome

Answer 82

Patients with angiodysplasia in the setting of aortic stenosis (known as Heyde syndrome) benefit from valve replacement surgery. While not FDA approved, thalidomide, which inhibits vascular endothelial growth factor, has shown some benefit in decreasing bleeding in patients with vascular malformations of the gut.

Question 83

Pancreatic neuroendocrine tumors

Answer 83

Initial evaluation includes blood and urine tests for chromogranin A, 5-hydroxyindoleacetic acid, gastrin, glucagon, insulin and proinsulin (if clinically indicated; requires fasting with concurrent glucose), pancreatic polypeptide, and vasoactive intestinal polypeptide to determine functional status. Most functional pancreatic neuroendocrine tumors secrete gastrin (gastrinoma) or insulin (insulinoma). For nonfunctional tumors associated with multiple endocrine neoplasia type 1 and von Hippel-Lindau syndrome, surgery is usually recommended if the tumors are greater than 2 to 3 cm in size.