Gastroenterology Flashcards
(184 cards)
1
Q
What’s the first study that should be ordered to evaluate dysphagia of unknown cause?
A
Barium study
2
Q
What is the pre-cancerous histologic change that affects the esophagus called?
A
Barrett esophagus
3
Q
Describe the presentation of achalasia.
A
Young nonsmoker w/ dysphagia to both solids and liquids
- may also have regurgitation of food and aspiration
- may be progressive
4
Q
What is the best initial test for achalasia? Most accurate?
A
First: Barium swallow or CXR
Most accurate: esophageal manometry
- endoscopy can be ordered to exclude malignancy but isn’t needed for dx of achalasia
5
Q
How does manometry assist in making the diagnosis of achalasia?
A
Shows an absence of normal esophageal peristalsis
- abnormally high pressure at lower esophageal sphincter (pathophysiology involves failure of gastroesophageal sphincter to relax)
- no mucosal abnormality
6
Q
How is achalasia treated? What are the associated risks?
A
Pneumatic dilation of the esophageal sphincter (risk of perforation) or surgical myotomy
Severe dz treated by per oral endoscopic myotomy (POEM)
- uses upper endoscopy to reach the surgical site
- a botulinum toxin injection may be used as an alternative if pt declines the above txs *
7
Q
What combinations of symptoms can you use to help distinguish between esophageal pathologies and cancer in a patient w/ dysphagia and weight loss?
A
Dysphagia + wt loss = esophageal pathology
Dysphagia + wt loss + heme-positive stool/anemia = cancer
8
Q
How does esophageal cancer present?
A
Dysphagia (first to solids, then liquids)
+ possible heme-positive stool/anemia
+ pt >50yo w/ smoking/EtOH hx
9
Q
What’s the best initial test if you suspect esophageal cancer?
A
Endoscopy; next option would be barium swallow
10
Q
How is esophageal cancer treated?
A
Surgical resection (if there are no local or distant mets) followed by 5-fluorouracil chemo
Palliative stenting can be performed to relieve obstruction
11
Q
What is the common underlying cause for esophageal webs and rings (aka “peptic strictures”)?
A
Repeated exposure of esophagus to stomach acid –> scarring and stricture formation
- previous use of sclerosing agents for variceal bleeding can also cause these problems, which is why variceal banding is preferred
12
Q
What constellation of symptoms is suggestive of eosinophilic esophagitis? How do you diagnose and treat it?
A
- Dysphagia
- Hx of allergies
Dx: Scope + biopsy
Tx: PPIs and budesonide
13
Q
What is Plummer-Vinson syndrome? How is it treated?
A
A proximal stricture a/w iron deficiency anemia and squamous cell esophageal cancer common in middle-aged women
Tx: iron replacement
14
Q
What is Schatzki ring? How do you treat it?
A
Peptic stricture of the distal ring of the esophagus that presents w/ intermittent dysphagia
Tx: pneumatic dilation
15
Q
How is peptic stricture from acid reflux treated?
A
Pneumatic dilation
16
Q
What procedures should be avoided in a patient w/ Zenker diverticulum?
A
Endoscopy and nasogastric tube placement
17
Q
What is a Zenker diverticulum? How does it present, and how do you treat it?
A
Dilation of posterior pharyngeal constrictor muscles diagnosed via barium study
- pt presents w/ dysphagia and very bad breath due to decomposing food retained in the diverticulum
Tx: surgical resection
18
Q
How does a case of diffuse esophageal spasm or nutcracker esophagus present? What test is best? How do you treat?
A
Sx: severe chest pain w/o risk factors for ischemic heart disease +/- dysphagia
- normal EKG, stress test, angiography
Dx: manometry
- barium swallow could show corkscrew pattern if it was performed during an acute attack
Tx: CCBs and nitrates (same as Prinzmetal angina)
- TCAs can be tried if CCBs aren’t an option
19
Q
How is Prinzmetal angina distinguished from diffuse esophageal spasm?
A
Prinzmetal angina will give ST elevation on EKG and abnormality on stimulation of coronary arteries
20
Q
How does scleroderma (progressive systemic sclerosis) present and how is it treated?
A
Presents as reflux w/ colonic dysmotility
Tx: PPIs
21
Q
How does esophagitis present?
A
Odynophagia, NOT dysphagia
22
Q
What is the most common cause of esophagitis in HIV-positive patients? What’s another less common cause?
A
In pts w/ <100 CD4 cells, candida esophagitis causes >90% of cases
- less commonly pill esophagitis from doxycycline, bisphosphonate, alendronate, etc.
23
Q
What advice should be given to patients experiencing pill esophagitis?
A
- Sit up and drink more water with pills
- Remain upright for >30 minutes after taking pill
24
Q
How does eosinophilic esophagitis present? What’s the relevant exam finding on endoscopy? What’s the relevant lab test?
A
Swallowing difficulty, food impaction, and heartburn in a pt w/ hx of asthma and allergic diseases
- multiple concentric rings on endoscopy
- biopsy finding w/ eosinophils (most accurate test)
25
How do you treat eosinophilic esophagitis? What's the single most effective treatment?
PPIs and elimination of allergenic foods
- most effective: swallowing steroid inhalers
26
How does treatment differ between patients with and without HIV in cases of esophagitis?
HIV-positive, <100 CD4s: fluconazole, then endoscopy if there's no response (**remember most cases are Candida)
HIV-negative: endoscopy before initiating treatment
27
What is a Mallory-Weiss tear?
A tear in the esophageal wall that presents w/ sudden upper GI bleeding w/ violent retching and vomiting
- may or may not have hematemesis or black stool
28
How do you diagnose and treat Mallory-Weiss tear?
Diagnose w/ endoscopy (barium swallow shows nothing)
* subcutaneous air seen only in perforation of the esophagus
Most cases resolve spontaneously
- if bleeding persists, inject epinephrine
29
Describe the symptoms of GERD.
- substernal chest pain
- epigastric pain
- sore throat
- metallic or bitter taste
- hoarseness
- chronic cough (20-25% of cases of chronic cough can also be diagnosed w/ GERD)
- wheezing
30
PPIs are both diagnostic and therapeutic for GERD. If there is no response to PPI therapy, what's your next step to make the diagnosis?
24-hour pH monitor
31
What is the initial treatment for mild GERD?
Lifestyle modification
- weight loss
- not eating within 3hrs of sleep
- elevating head of bed
- quit smoking
- limit EtOH, caffeine, chocolate, mint
32
If lifestyle modifications don't work to treat GERD, what are the other options?
- PPIs achieve control in 95% of cases (all options are equal in efficacy)
- H2 blockers (cimetidine, famotidine, nizatidine) have a 70% success rate
- promotility agents (metoclopramide) are equal to H2 blockers in efficacy but less effective than PPIs
- surgical or endoscopic procedure to narrow distal esophagus and re-constrict lower esophageal sphincter (Nissen fundoplication)
33
How does high calcium cause ulcers?
Stimulates gastrin release
34
When is reflux an alarming symptom that warrants endoscopy?
When associated w/ weight loss, anemia, blood in the stool, and dysphagia
35
What is Barrett esophagus?
A precancerous lesion (0.5% of cases per year develop into cancer) diagnosed by endoscopy and biopsy that confirms change of squamous epithelium to columnar epithelium w/ metaplasia
36
How is Barrett esophagus treated? Low-grade dysplasia? High-grade dysplasia?
Barrett: PPI and repeat endoscopy q3-5 years
Low-grade dysplasia: PPI, ablation, repeat endoscopy in 3-6mo
High-grade dysplasia: endoscopic mucosal resection, ablative removal, or distal esophagectomy
37
What is the most common cause of epigastric discomfort?
Functional (nonulcer) dyspepsia, which is a diagnosis of exclusion
- diagnosed after endoscopy has ruled out ulcers, cancer, and gastritis
38
How do you treat functional dyspepsia?
Symptomatic treatment w/ H2 blockers, liquid antacids, or PPIs
- you can treat for Helicobacter in refractory disease
39
Can you distinguish between duodenal ulcer and gastric ulcer without endoscopy?
No, though generally food makes gastric ulcer pain worse and duodenal ulcer pain better.
40
What MUST be done in a patient over 60yo with epigastric pain?
Scope to rule out gastric cancer
41
How do you treat Helicobacter pylori?
PPI + clarithromycin + amoxicillin
- increasing macrolide resistance is increasing the use of metronidazole and bismuth as adjunct
* only treat H. pylori when a/w gastritis; there's no benefit in GERD
42
What do you do if PPI + clarithromycin + amoxicillin doesn't successfully treat H pylori?
Repeat treatment w/ metronidazole and tetracycline + PPI; consider adding bismuth
- if repeat course fails, evaluate for Zollinger-Ellison
43
What are the adverse effects of PPIs?
- impaired calcium absorption (may lead to fractures)
- impaired magnesium absorption
- impaired vitamin B12 absorption
- impaired iron absorption
- impaired resistance to bacterial invasion (reduced acid barrier --> increased risk of pna and C. Diff)
- impaired kidney function leading to interstitial nephritis (eosinophils in urine)
44
What are the primary conditions that lead to stress peptic ulcers?
Head trauma, intubation/ventilation, burns, coagulopathy + steroid use
45
Which medications are most effective at preventing stress ulcers?
PPI >> H2 blocker, sulcrafate
46
What is Zollinger-Ellison syndrome? How is it diagnosed?
aka gastrinoma
- elevated gastrin level
- elevated gastric acid output
47
What are the characteristics of a normal peptic ulcer? What are the characteristics of ulcers suspicious for Zollinger-Ellison syndrome?
Normal: single ulcer near pylorus, <1cm, resolves easily w/ tx
ZES: multiple large ulcers, >1cm, distally located near ligament of Treitz, recurrent or resistance despite adequate treatment
48
If hypercalcemia is present along w/ multiple large distally-located, treatment-resistant gastric ulcers, what do you suspect?
Parathyroid problem + Zollinger-Ellison syndrome, which together raise the suspicion for multiple endocrine neoplasia (MEN) syndrome
49
Which medications cause elevated gastrin levels?
H2 blockers and PPIs
50
Which tests are appropriate for Zollinger-Ellison syndrome? Which is most accurate?
- endoscopic ultrasound
- nuclear somatostatin scan (very sensitive b/c ZES causes huge increase in # of somatostatin receptors)
- secretin suppression (most accurate!!)
51
What is the treatment for Zollinger-Ellison?
Surgical resection for local disease and lifelong PPIs for metastatic dz
52
How does secretin suppression test for Zollinger-Ellison syndrome?
Infusion of IV secretin causes healthy people to decrease gastrin level and acid output
ZES pts will show increased or unchanged gastrin level and no decrease in acid output
53
What are the extra-intestinal manifestations of IBD?
- joint pain
- iritis/uveitis
- pyoderma gangrenosum, erythema nodosum
- sclerosing cholangitis
54
Which features are more common in Crohn disease than ulcerative colitis?
- masses
- skip lesions
- upper GI tract involvement
- perianal disease
- transmural granulomas
- fistulae
- hypocalcemia from fat malabsorption
- obstruction
- calcium oxalate kidney stones
- cholesterol gallstones
- vitamin B12 malabsorption
55
What tests are used in diagnosis of IBD?
- endoscopy
- barium study
- blood tests (if diagnosis is not clear)
- fecal calprotectin (made by WBCs) to track disease activity
56
How are fecal calprotectin levels interpreted in cases of possible IBD?
High in IBD and bowel infection
Low in absence of infection/inflammation
57
Which blood tests can be used to assist in the diagnosis of IBD?
ASCA (positive in Crohn's, negative in UC)
ANCA (negative in Crohn's, positive in UC)
58
How does IBD impact the need for colon cancer screening?
CD w/ colonic involvement and UC can lead to colon cancer
After 8-10 years of colonic involvement, colonoscopies should be completed every 1-2 years
59
What is the best initial treatment for both Crohn's and ulcerative colitis?
Mesalamine
- not sulfasalazine due to side effects (rash, hemolytic anemia, interstitial nephritis)
60
What are the treatments for IBD?
Mesalamine (best initial)
Steroids
- budesonide (glucocorticoid) for control of acute exacerbations has limited systemic adverse effects
Azathioprine and 6-mercaptopurine
-for severe disease w/ recurrent symptoms after steroid cessation
- can help pts wean off steroids
- thiopurine methyltransferase (TPMT) testing can help ensure pts can metabolize potentially toxic metabolites of these drugs
TNF inhibitors
- for CD a/w fistula formation
- test for and start treatment for latent TB before initiating infliximab bc it can reactivate TB by releasing it from granulomas
- you don't have to complete tx before starting infliximab or JAK inhibitor, just start it
Metronidazole + ciprofloxacin
- for perianal involvement in Crohns
Vedolizumab (IV integrin receptor antagonist)
- for severe IBD not controlled by other txs
- induces and maintains remission w/o risk of PML
61
What role does surgery play in IBD treatment?
Can be curative in UC by removing colon, but CD will still recur at surgical site
*surgery may still be necessary in Crohns in the event of stricture or obstruction
62
Which TNF inhibitors may be used in IBD? How can you monitor and adjust for effectiveness?
Adalimumab, certolizumab, etanercept, golimumab, and infliximab
If ineffective, check TNF level and antibodies and switch TNF drugs.
If level is normal but there are no antibodies, switch drug class.
63
What is the most important feature of infectious diarrhea presentation in regards to diagnosis and management?
Presence or absence of blood; blood indicates presence of invasive bacteria
64
Which bacteria is the most common cause of food poisoning?
Campylobacter (may be associated w/ Guillain-Barre and reactive arthritis)
65
Which bacteria is transmitted by chickens/eggs? Associated w/ seafood?
Chickens: salmonella
Seafood: vibrio
66
Which bacteria is most commonly associated w/ hemolytic uremic syndrome (HUS)?
E. coli 0157:H7, which secretes verotoxin and is associated w/ undercooked beef
67
What common treatments can worsen HUS?
Platelet transfusions and antibiotics
68
Which infectious diarrhea patient makes you suspicious for Vibrio vulnificus?
Shellfish consumption in a person w/ liver disease and skin lesions
69
Which bacteria responsible for infectious diarrhea are associated w/ reactive arthritis?
Campylobacter and Shigella (shiga toxin)
70
What defines severe disease in a patient with infectious diarrhea?
Presence of blood, fever, abdominal pain, hypotension/tachycardia
71
How do you treat mild vs severe cases of infectious diarrhea?
Mild: hydration only; dz is time-limited
Severe: fluroquinolones (ciprofloxacin or azithromycin)
72
Which pathogens cause exclusively non-bloody diarrhea?
Viruses: rotavirus, norovirus, hepatitis A/E
Giardia
Staph aureus
Bacillus cereus
Cryptosporidiosis
Scombroid (histamine fish poisoning)
73
What history should raise suspicion for Giardia infection? What's the testing and treatment?
Camping, hiking, and contact w/ feces (changing diapers, sexual contact, etc.)
Test: stool ELISA antigen >90% sensitive/specific (better than O&P)
Tx: metronidazole or tinidazole
74
How does staph aureus diarrhea present and what's the disease course?
Vomiting + diarrhea; resolves spontaneously
75
What exposure is associated w/ Bacillus cereus? What's the disease course?
A/w refried/reheated Chinese rice and vomiting; resolves spontaneously
76
Which patient w/ non-bloody diarrhea should make you suspicious for Cryptosporidiosis?
HIV-positive pt w/ CD4 <100
77
How do you diagnose cryptosporidiosis? How do you treat it?
Dx: modified acid-fast stain
Tx: antiretrovirals to raise CD4 levels (nitazoxanide and paromycin)
78
Describe the presentation and treatment of scombroid diarrhea.
Histamine fish poisoning (toxic levels of histamine present in improperly stored fish like tuna, mackerel, or mahi-mahi)
- rapid onset of diarrhea and wheezing within ten minutes of eating fish
- Tx: antihistamines like diphendyramine
79
Which antibiotic is most commonly associated w/ C. Diff?
Clindamycin (but can be caused by ANY abx)
80
Which is the best initial test for C. diff? Most accurate?
Initial: stool toxin assay
Most accurate: stool PCR
81
What is the treatment for C. diff?
PO vancomycin (PO fidaxomicin as alternative) ** IV is not useful!
- if diarrhea resolves then recurs, retreat w/ PO vanc
- add metronidazole if dz is severe
- stool transplant after multiple recurrences
82
What are indications for surgery in C. diff? What agent can be used to prevent recurrence?
Surgery for severe dz: toxic megacolon, elevated lactate, leukocytosis, elevated creatinine
Prevent recurrence: bezlotoxumab
83
What is the most common cause of chronic diarrhea and flatulence?
Lactose intolerance
84
What is carcinoid syndrome? How is it diagnosed? How do you treat?
Chronic secretory diarrhea a/w flushing and episodes of hypotension
Dx: urinary 5-HIAA level
** not pre-malignant, not an indication for additional surveillance **
Tx: octreotide (somatostatin analog)
85
What are the causes of fat malabsorption?
Celiac disease
Non-tropical or tropical spure
Chronic pancreatitis
Whipple disease
86
All forms of fat malabsorption are associated w/ what features?
- hypocalcemia from vitamin D deficiency (may lead to osteoporosis)
- oxalate overabsorption --> oxalate kidney stones
- vitamin K malabsorption --> easy bruising, elevated prothrombin time/INR
- vitamin B12 malabsorption from destruction of terminal ileum or loss of pancreatic enzymes necessary for B12 absorption
87
What is the diagnostic testing for fat malabsorption?
Sudan black stain of stool to test for presence of fat (initial test)
72-hour fecal fat (most sensitive)
88
In addition to fat, what other malabsorption(s) and resulting condition(s) is associated w/ celiac disease?
Malabsorption of Fe ==> microcytic anemia
* this fact differentiates it from pancreatic insufficiency
Malabsorption of folate from destruction of villi
89
What skin lesion is associated w/ celiac disease?
Vesicular skin lesion not present on mucosal surfaces called dermatitis herpetiformis
90
What are the diagnostic tests for celiac disesase?
- Antigliadin, anti-endomysial, and anti-tissue transglutaminase Abs (best initial)
- small bowel biopsy (most accurate)
- D-xylose (also abnormal in Whipple disease and tropical sprue) usually not necessary
*biopsy is necessary to exclude bowel wall lymphoma
91
How does tropical sprue present? What are the diagnostic tests and treatment?
Presents like celiac disease but w/ history of being in the tropics
- serologic tests (anti-tissue transglutaminase) will be negative
- most accurate test is small bowel biopsy showing microorganisms
Tx: doxycycline or TMP/SMX 3-6 months
92
What findings on presentation help distinguish Whipple disease from celiac/sprue?
Arthralgia, neurological abnormalities, ocular findings
93
What testing is needed to diagnose Whipple disease? Treatment?
Small bowel bx w/ PAS-positive organisms (most accurate)
- alternately: PCR of stool for tropheryma whippeli
Tx: TMP/SMX or doxy for 12 months
94
What is the presentation of chronic pancreatitis?
Fat malabsorption w/ history of alcoholism and/or multiple episodes of pancreatitis
- amylase + lipase likely normal
- malabsorption of vit K/D less common than with celiac disease
- Fe and folate levels normal
- B12 may be low
- D-xylose testing normal
95
What are the best initial and most accurate tests for chronic pancreatitis? What's the treatment?
Initial: Abdominal x-ray (50-60% sensitive for detection of pancreatic calcifications), abdominal CT w/o contrast (60-80% sensitive)
Most accurate: secretin stimulation testing
Tx: long-term PO replacement of pancreatic enzymes (amylase, lipase, trypsin)
96
What are three key factors in the history that help differentiate IBS from IBD?
IBS w/ have no fever, weight loss, or bloody stool
97
How does IBS present?
- abdominal pain relieved by bowel movement
- abdominal pain which is better at night
- abdominal pain with diarrhea alternating w/ constipation
Normal diagnostic tests: stool guaiac, stool leukocytes, culture, O&P, colonoscopy, abdominal CT
98
How do you treat IBS?
Fiber (increased stool bulk helps relieve pain)
- if fiber doesn't help pain, add antispasmodic/anticholinergic agents (dicyclomine, hyoscyamine)
- if no response, add tricyclic antidepressant (amitriptyline)
99
What medications can be helpful for diarrhea-prominent IBS?
Rifaximin, Alosetron, Eluxadoline, Tenapenor
100
What are some key principles for treating constipation-prominent IBS?
Start w/ fiber, then try miralax, then chloride-channel activator (lubiprostone) or guanylate cyclase agonist (linaclotide or plecanatide)
101
What are the screening guidelines for general population colon cancer?
General population: 45yo, colonoscopy q10 years (OR sigmoidoscopy q5 years, fecal immunochemistry and stool DNA q3 years)
- FOBT and scope yearly if colonoscopy (+)
102
What are the screening guidelines for pts w/ one family member w/ colon cancer?
One family member w/ colon Ca: 40yo OR 10yrs before age at which family member was diagnosed
103
What are the colon cancer screening guidelines for pts w/ three family members, two generations, or one family member diagnosed <50yo?
Colonoscopy starting at age 25, repeat q1-2 years (suspect Lynch syndrome or hereditary nonpolyposis colon cancer)
104
What are the colon cancer screening guidelines for patients w/ familial adenomatous polyposis?
Begin screening sigmoidoscopy at 12yo at perform colectomy when polyps are found
105
What is Gardner syndrome?
Subvariant of FAP that presents w/ benign bone tumors (osteomas) and other soft tissue tumors
- long-term risk of colon cancer plus thyroid, pancreas, and small bowel cancer
*screen w/ sigmoidoscopy starting at 12yo same as FAP
106
How does Peutz-Jeghers present? How does it impact cancer screening?
Melanotic spots on the lips + hamartomatous polyps throughout small bowel and colon
- risk of cancer VERY high
- screening w/ sigmoidoscopy at 8yo
107
What is juvenile polyposis? How does it impact cancer risk?
Multiple extra hamartomas in bowel
- risk of cancer and premature cancer is high
- screen upper and lower GI tract starting at 12yo
108
How does colon cancer screening change when a dysplastic polyp is found?
Repeat colonoscopy in 3-5 years
109
Is carcinoembryonic antigen a screening test?
NO. It is used to monitor response to therapy.
110
What causes diverticulosis and how does it present? How do you manage it?
Caused by low-fiber, high-fat, low-residue diet
Sx: LLQ pain + lower GI bleed
Dx: colonoscopy
Tx: high-fiber diet
111
What is diverticulitis and how does it present? How do you manage it?
Complication of diverticulosis that presents with LLQ pain, tenderness, fever and leukocytosis
- Dx: CT abdomen/pelvis
- Tx: abx w/ gram (-) and anaerobic coverage (ex: quinolone/cephalosporine [usually cipro] + metronidazole)
** colonoscopy/barium swallow are contraindicated bc of increased risk of perforation
112
What do you order on CCS for large-volume GI bleeding?
- Bolus NS or LR
- CBC
- PT/INR
- type and cross
- consult GI
- EKG
113
Unnecessary use of prophylactic PPIs increases risk of what two conditions?
PNA and C. diff
114
Which type of GI bleed has the highest mortality?
Varices
115
What features should raise your suspicion for variceal bleeds?
Pt w/ EtOH use and hematemesis and/or liver disease
- splenomegaly
- low platelets
- spider angiomata
- gynecomastia
116
How do you treat variceal bleeding?
- octreotide (somatostatin analog to decrease portal HTN)
- ceftriaxone if ascites is present (for SBP prophylaxis)
- stat EGD
- TIPS procedure if bleeding persists
*propranolol can be used to prevent future episodes
117
What is the role of Blakemore gastric tamponade balloon in management of variceal bleeding?
(rarely used)
will temporarily stop bleeding to allow shunt to be placed
118
What is the most common complication of TIPS procedure?
Hepatic encephalopathy
119
What is the goal INR in a patient w/ variceal bleeding?
<1.4
120
What are the common causes of upper GI bleeds?
- ulcer disease
- esophagitis, gastritis, duodenitis
- varices
- cancer
121
What are the common causes of lower GI bleeds?
- angiodysplasia
- diverticular dz
- polyps
- ischemic colitis
- IBD
- cancer
122
What diagnostic procedures can you use to identify the location of GI bleeding if endoscopy does not?
- technetium bleeding scan (tagged RBC scan)
- angiography (can be done pre-op to target resection)
- capsule endoscopy (for small bowel)
123
When do you transfuse packed RBCs?
Hematocrit <30 in older patient or <20-25 in younger patient w/o heart disease
124
When do you transfuse FFP?
When PT/INR is elevated and vitamin K is too slow
125
When do you transfuse platelets?
When patient is bleeding or scheduled for surgery and platelets are <50K
126
What is the most common cause of death in pts w/ GI bleeding?
Myocardial ischemia
- myocytes of LV cannot distinguish b/tw ischemia, anemia, carbon monoxide poisoning, or coronary artery stenosis ==> all lead to MI
* order EKG in older pts w/ GI bleed
127
When do patients w/ GI bleeds need an NG tube?
When it's unclear whether bleeding is from upper or lower GI, but this offers limited info and doesn't change anything if the patient is going to be scoped anyway
*iced saline lavage is never the right answer
128
What are some possible causes of constipation?
- dehydration
- CCBs
- narcotics
- hypothyroidism
- DM (loss of sensation in bowel)
- Fe sulfate
- Anticholinergics and TCAs
129
What is dumping syndrome?
Relatively rare downstream effect of gastric surgery (ex: Roux-en-Y) that presents w/ shaking, sweating, and weakness
- may involve hypotension
- tx: frequent small meals
130
What is diabetic gastroparesis and how do you treat it?
Impaired neural supply to the bowel 2/2 longstanding diabetes which impairs normal motility
- Tx: erythromycin or metoclopramide (erythromycin increases motilin levels in the gut)
131
How does acute pancreatitis present? What are the common causes?
Severe mid-epigastric pain and tenderness in an alcoholic pt or someone w/ gallstones
- non-bloody vomiting, anorexia, tenderness
- (severe cases) hypotension, metabolic acidosis, leukocytosis, hemoconcentration, hyperglycemia, hypocalcemia 2/2 fat malabsorption, hypoxia
Causes: hypertriglyceridemia, trauma, infection, ERCP, meds (thiazides, didanosine, stavudine, azathioprine)
132
What are the diagnostic tests for acute pancreatitis?
- Amylase and lipase (best initial)
- CT abdomen (dilated common bile ducts; most accurate)
- MRCP
- ERCP (predominantly therapeutic)
133
How do you treat acute pancreatitis?
- bowel rest
- hydration
- pain management
134
What are Ranson criteria?
Operative criteria to see which patient's need pancreatic debridement (severity is mostly determined by CT now)
135
What is the treatment for necrotic pancreatitis?
If CT shows >30% necrosis of the pancreas: abx (imipenem) + CT-guided bx
If bx shows infection: necrotic pancreatitis ==> surgical debridement
136
How do patients with acute hepatitis present?
- jaundice
- fatigue
- weight loss
- dark urine (bilirubin)
- serum sickness phenomena (joint pain, urticaria, fever --> Hep B/C)
- polyarteritis nodosa (hep B)
- cryoglobulinemia (hep C)
137
Which hepatitis is most severe in pregnancy?
Hep E (can be fatal)
138
What are the diagnostic tests for acute hepatitis?
- elevated conjugated (direct) bilirubin
- bilirubin in urine
- unconjugated bilirubin does not pass into urine
139
What are the diagnostic test findings for viral hepatitis?
Elevated ALT
140
What are the diagnostic test findings for drug-induced hepatitis?
Elevated AST
141
What are the diagnostic test findings for hepatitis A, C, D, E?
Serology for antibodies (most accurate)
142
What are the diagnostic test findings for hepatitis B?
surface antigen, core antibody, e-antigen, or surface antibodies (most accurate)
143
What is the first test to become abnormal in acute hep B?
Surface antigen
- elevation of ALT, e-antigen and symptoms occur afterward
144
What lab abnormalities differentiate chronic hep B from acute?
Chronic has the same serologic pattern but surface antigen persists >6mo
145
What is the status of surface antigen, e-antigen, core antibody, and surface antibody in acute hep B, window period, vaccinated individuals, and healed/recovered hep B?
Acute dz: surface (+), e (+), core (+), surface (-)
Window period: surface (-), e (-), core (+), surface (-)
Vaccinated: surface (-), e (-), core (-), surface (+)
Recovered: surface (-), e (-), core (+), surface (+)
146
Is there a treatment for acute hep B?
No
147
Which lab tests indicate active viral replication?
Hep B DNA polymerase = e-antigen = Hep B PCR for DNA
(all equivalent tests)
148
Which is the only acute hepatitis that has a treatment available?
Hep C
149
What is the best initial test for acute Hep C?
Hep C ab (cannot tell activity level of virus and stays positive after treatment)
150
What is the most accurate test to tell the activity level of the Hep C virus and degree of viral replication?
Hep C PCR for RNA (also most accurate to determine response to therapy)
151
What is the most accurate test to determine the seriousness of acute hep c?
Liver biopsy
- pt can have up to 10yrs of viral replication w/ relatively little liver damage
- bx can determine extent of liver damage but isn't necessary to determine need for tx
152
Which patient with chronic Hep B is most likely to benefit from antiviral therapy? (serologic results)
Pt w/ surface antigen, e-antigen and DNA polymerase or PCR for DNA
- look for >6mo positive serology
153
What is the treatment for chronic hep B?
ONE of the following
- tenofovir
- lamivudine
- adefovir
- entecavir
- telbivudine
- interferon (ONLY when pt has hep D co-infection)
154
What are the side effects of tenofovir?
Bone demineralization and renal tubular acidosis (affects proximal convoluted tubule)
155
What are the side effects of interferon?
- flu-like sxs
- arthralgia/myalgia
- fatigue
- depression
- thrombocytopenia
156
Who should be tested for Hep C?
Everyone 18yo+
157
How can you assess for cirrhosis in chronic hep C pts w/o biopsy?
Liver elastography (non-invasive) to assess liver fibrosis
- can determine who may need EGD and beta-blockers to prevent bleeding
158
What is the treatment for chronic hep C? What is required prior to initiating tx?
FIRST: genotype of virus determines which treatment combo is ideal
- PO tx for 12wks
- all genotypes can be treated w/ sofosbuvir/velpatasvir or glecaprevir/pibrentasvir
159
How do you assess the cure success in chronic hep C?
Suppressed PCR-RNA viral load 12 and 24 weeks after therapy stops
160
When is Hep A/B vaccination given? What are specific indications for it?
Given in childhood to all patients
Special considerations:
Hep A --> travelers and homeless
Hep B --> healthcare workers, pts on dialysis, diabetes
161
What are the strongest indications for vaccination against both Hep A and B in adults?
- chronic liver dz (greater risk of fulminant hepatitis if infected)
- household contacts w/ hep A or B
- men who have sex w/ men
- chronic recipients of blood products
- injection drug users
162
How is Hep E acquired? What population is at highest risk and what's the disease course?
Fecal-oral transmission (greater in poor countries)
- worse in pregnant women
- can progress to chronic disease in immunosuppressed pts
- usually resolves spontanteously (ribavirin/interferon in immunosuppressed pts)
163
What is the post-exposure prophylaxis for Hep A?
Hep A vaccine is enough
- single dose for pts over 12mo
- if immunocompromised or has chronic liver disease --> immune globulin
164
What are the key features of cirrhosis?
- edema (from low oncotic pressure)
- gynecomastia
- palmar erythema
- splenomegaly
- thrombocytopenia (2/2 splenic sequestration)
- encephalopathy
- ascites
- esophageal varices
165
How do you treat edema associated w/ cirrhosis?
Spironolactone and diuretics
166
How do you treat encephalopathy associated w/ cirrhosis?
Lactulose and/or rifaximin
167
What are the HCC screening guidelines for pts w/ cirrhosis?
US every 6mos
- 95% sensitive at detecting cancer
168
Which pts w/ ascites need paracentesis?
New ascites or old ascites w/ pain, fever, or tenderness
169
What tests should be performed on ascitic fluid from paracentesis? What do they indicate?
Fluid albumin level
- serum-to-ascites albumin gradient (SAAG) >1.1 ==> portal HTN from cirrhosis or congestive failure is present
Fluid cell count
- >250 neutrophils ==> SBP
170
What is the treatment of SBP?
Cefotaxime or ceftriaxone
- any pt who has had SBP needs lifelong prophylaxis w/ TMP/SMX or norfloxacin
171
What is primary biliary cholangitis?
Cause of cirrhosis which presents in middle-aged women complaining of itching
- increases risk of osteoporosis
- xanthelasmas (cholesterol deposits) on exam
- may have hx of immune disorders
172
What are the best initial and most accurate tests for primary biliary cholangitis?
Initial: elevated alk phos w/ normal bilirubin, elevated IgM
Most accurate: antimitochondrial antibody (AMA), liver bx
173
What is the treatment for primary biliary cholangitis?
Ursodeoxycholic acid
- if no response, add obeticholic acid (suppresses bile acid synthesis)
- if itching, add antihistamine
Cholestyramine can improve symptoms
174
What is primary sclerosing cholangitis? What's the most accurate test?
Sequela of IBD in 80% of cases and cause of cirrhosis
- presents w/ itching, elevated bilirubin and elevated alk phos
ERCP: beading of biliary system
anti-smooth muscle antibody (ASMA) and ANCA positive
175
What is the treatment for primary sclerosing cholangitis?
Ursoeoxycholic acid
176
What is Wilson disease? How is it diagnosed?
Cirrhosis and liver dz in a pt w/ choreiform movement d/o and neuropsychiatric abnormalities and hemolysis
Best initial test: slit lamp for Kayser-Fleischer rings > ceruloplasmin level (low)
Most accurate: liver bx
177
What is the treatment for Wilson disease?
Penicillamine or trientine +/- zinc
178
What is hemochromatosis?
Cause of cirrhosis due to genetic disorder causing overabsorption of Fe
- Fe deposits throughout body, mostly in liver
- restrictive cardiomyopathy
- skin darkening
- joint pain (pseudogout or calcium pyrophosphate deposition dz)
- pancreas damage (leads to diabetes)
- pituitary accumulation w/ panhypopituitarism
- infertility
- hepatoma
179
What are the diagnostic tests for hemochromatosis?
Best Initial: elevated serum Fe and ferritin w/ low TIBC; iron saturation >45%
Most Accurate: liver biopsy
- MRI + HFe gene mutation test can be used to avoid biopsy
180
What is the treatment of hemochromatosis?
Phlebotomy
* Fe chelators (deferasirox/deferiprone used only for overtransfusion, not genetic overabsorption)
181
What is the classic presentation of autoimmune hepatitis?
Young woman w/ autoimmune diseases like Coombs positive hemolytic anemia, thyroiditis, and ITP
182
What are the diagnostic tests and treatment for autoimmune hepatitis?
Best initial: ANA (+), antismooth muscle antibody, serum protein electrophoresis (hypergammaglobulinemia)
Most accurate: liver biopsy
Tx: prednisone
- immunosuppressants like azathioprine may be needed to help wean pt off steroids
183
What are the two degrees of NAFLD?
Nonalcoholic fatty liver (NAFL): milder; doesn't cause cirrhosis
Nonalcoholic steatohepatitis (NASH): more severe; leads to cirrhosis and possibly cancer
- strongly associated w/ T2DM, obesity, HLD
184
What are the tests and treatments for NAFLD?
Best initial: ALT > AST
Most accurate: liver bx w/ fatty liver infiltration (looks like alcoholic liver dz)
Tx: control underlying causes
- if diabetes, pioglitazone is best initial therapy
