Gastroenterology Flashcards
(575 cards)
1
Q
Most nutrient absorption occurs in the ___
A
small intestine
2
Q
most common maldigestion syndrome
A
lactase deficiency
3
Q
most common cause of small bowel obstruction
A
adhesions
4
Q
most common cause of colonic obstruction
A
colonic CA
5
Q
The best accepted symptom-based criteria are the Rome criteria, which exhibit sensitivities and specificities of only ___ to ___% when tested against structural findings in IBS and functional dyspepsia, indicating a need for careful test selection in patients at high risk of organic disease.
A
55–75
6
Q
In patients with GI complaint, fever suggests ____ or ____
A
inflammation or neoplasm
7
Q
Fecal elastase can be decreased with ______
A
exocrine pancreatic insufficiency
<100 ug per gram of stool
8
Q
mainstay of managing intestinal bacterial overgrowth
A
oral antibiotics
9
Q
CT colonography rivals the accuracy of colonoscopy for the detection of some polyps and cancer, although it is not as sensitive for the detection of ______
A
flat lesions, such as serrated polyps
10
Q
Flexible sigmoidoscopy is akin to colonoscopy, but it visualizes only the rectum and a variable portion of the left colon, typically to ___ cm from the anal verge
A
60
11
Q
What modality provides the most accurate preoperative local staging of esophageal, pancreatic, and rectal malignancies?
A
EUS
However, does not detect most distant metastases
12
Q
primary diagnostic and therapeutic technique for patients with acute gastrointestinal hemorrhage
A
Endoscopy
13
Q
Over ___% of patients with melena are bleeding proximal to the ligament of Treitz, and ~___% of patients with hematochezia are bleeding from the colon.
A
90
85
14
Q
A single dose of what antibiotics may administered intravenously 30–90 min prior to upper endoscopy increases gastric emptying and may clear blood and clots from the stomach to improve endoscopic visualization
A
erythromycin 3–4 mg/kg or 250 mg)
15
Q
what endoscopic procedures would need abx prophylaxis?
A
see table
16
Q
A clean based ulcer is associated with a low risk (___%) of rebleeding
A
3-5
patients with melena and a clean-based ulcer may be discharged home from the emergency room or endoscopy suite if they are young, reliable, otherwise healthy, and able to return as needed.
Once daily PPI
17
Q
Flat pigmented spots and adherent clots covering the ulcer base have a % and % risk of rebleeding, respectively.
A
10 (mnemonic flattened –> flat-TEN)
20
Flat pigmented spots do not require endoscopic treatment, but endoscopic therapy is generally applied to an ulcer with an adherent clot.
Once daily PPI
18
Q
When a fibrin plug is seen protruding from a vessel wall in the base of an ulcer (so-called sentinel clot or visible vessel), the risk of rebleeding from the ulcer approximates __%.
A
40
leads to endoscopic therapy to decrease the rebleeding rate.
19
Q
When active spurting from an ulcer is seen, there is a ___% risk of ongoing bleeding without endoscopic or surgical therapy.
A
90%
20
Q
_____ is indicated for the prevention of a first bleed (primary prophylaxis) from large esophageal varices particularly in patients in whom nonselective beta blockers are contraindicated or not tolerated.
A
Endoscopic variceal ligation
EVL is also the preferred endoscopic therapy for control of active esophageal variceal bleeding and for subsequent eradication of esophageal varices (secondary prophylaxis).
21
Q
Which antithrombotic drugs should be discontinued when performing endoscopic procedures?
A
Low-dose aspirin does not substantially increase the risk of endoscopic procedures
All blood thinners + high risk procedure –> withold EXCEPT aspirin WITHOUT dypiridamole –> may continue
If high risk + stent and P2 Y12 –> discuss first with cardio
If high risk NO stend but on P2Y12 –> discontinue or consider switching to aspirin
See table
22
Q
Also called persistent caliber artery, is a large-caliber arteriole that runs immediately beneath the gastrointestinal mucosa and bleeds through a focal mucosal erosion
A
Dieulafoy’s Lesion
commonly involves the LESSER curvature of the proximal stomach, causes impressive arterial hemorrhage, and may be difficult to diagnose when not actively bleeding; it is often recognized only after repeated endoscopy for recurrent bleeding
23
Q
best method for diagnosis of mallory weiss tear
A
Endoscopy
24
Q
Endoscopy is useful for evaluation and treatment of some forms of gastrointestinal obstruction. An important exception is ____
A
small bowel obstruction due to adhesions
25
What imaging should be considered before endoscopy in patients fever, esophageal obstruction for ≥24 h, or ingestion of a sharp object, such as a fishbone?
Radiographs of the chest and neck
Radiographic contrast studies interfere with subsequent endoscopy and are NOT advisable in most patients with a clinical picture of esophageal obstruction.
26
The risk of cecal perforation in pseudoobstruction rises when the cecal diameter exceeds ___
12 cm
decompression of the colon may be achieved using intravenous neostigmine or via colonoscopic decompression
27
procedure of choice since it remains the gold standard for diagnosis and allows for immediate treatment of acute biliary obstruction
ERCP
28
Charcot’s triad
Charcot’s triad of jaundice, abdominal pain, and fever is present in ~70% of patients with ascending cholangitis and biliary sepsis
29
Reynolds Pentad
Chartcots triad (jaundice, abdominal pain, fever) + confusion and hypotension
30
The most sensitive test for diagnosis of gastroesophageal reflux disease (GERD) is ______
24-h ambulatory pH monitoring.
31
Endoscopy should be considered in patients with long-standing (≥___ years) GERD, as they have a sixfold increased risk of harboring Barrett’s esophagus compared to patients with <1 year of reflux symptoms
10
32
precursor lesion of esophageal squamous cell cancer
Esophageal squamous dysplasia
33
the most common type of esophageal malignancy worldwide
esophageal SCCA
34
About __% of patients presenting with difficulty swallowing have a mechanical obstruction; the remainder has a motility disorder, such as achalasia or diffuse esophageal spasm
50%
35
How do you distinguish dysphagia from schatzkis ring vs oropharyngeal motor disorders vs achalasia based on symptoms?
Schatzki’s ring causes episodic dysphagia for solids, typically at the beginning of a meal; oropharyngeal motor disorders typically present with difficulty initiating deglutition (transfer dysphagia) and nasal reflux or coughing with swallowing; and achalasia may cause nocturnal regurgitation of undigested food
36
When transfer dysphagia is evident or an esophageal motility disorder is suspected, _______ and/or _____ are the best initial diagnostic tests
esophageal radiography and/or a video-swallow study
37
Tests for occult blood in the stool detect hemoglobin or the heme moiety and are most sensitive for ___ blood loss, although they will also detect larger amounts of upper gastrointestinal bleeding
colonic
If positive, patients should undergo colonoscopy to diagnose or exclude colorectal neoplasia, especially if they are >50 years old or have a family history of colonic neoplasia.
38
In contrast to the low diagnostic yield of smallbowel radiography, positive findings on capsule endoscopy are seen in 50–70% of patients with suspected small-intestinal bleeding. The most common finding is _____
mucosal vascular ectasia
39
Even trivial amounts of hematochezia should be investigated with colonoscopy and/or flexible sigmoidoscopy together with anoscopy to exclude polyps or cancers, especially in patients >__ years old and those with a personal or family history of colorectal polyps or cancer.
40
Patients reporting red blood on the toilet tissue only, without blood in the toilet or on the stool, are generally bleeding from a lesion in the anal canal; careful external inspection, digital examination, and sigmoidoscopy with anoscopy may be sufficient for diagnosis in such cases.
40
Previously undetected chronic pancreatitis, pancreatic malignancy, or pancreas divisum may be diagnosed by either ___ or ___
ERCP or EUS
41
When should you screen patients for colon CA?
Note: long standing IBD --> colonic biopsy every 1-2yrs
see table
42
Appendiceal fecaliths (or appendicoliths) are found in ~__% of patients with gangrenous appendicitis who perforate but are rarely identified in those who have simple disease.
50
43
In patients with acute appendicitis The pain subsequently migrates to the right lower quadrant over ___ h, where it is sharper and can be definitively localized as transmural inflammation when the appendix irritates the parietal peritoneum.
12-24
44
Most common symptom of acute appendicitis
Abdominal pain
45
Most common sign of acute appendicitis
Abdominal tenderness
46
Location of appendix that may not present with very little tenderness of anterior abdominal wall
An inflamed appendix located behind the cecum or below the pelvic brim may prompt very little tenderness of the anterior abdominal wall.
Patients with pelvic appendicitis are more likely to present with dysuria, urinary frequency, diarrhea, or tenesmus.
47
The provider should be concerned about other disease processes beside appendicitis or the presence of complications such as perforation, phlegmon, or abscess formation if the temperature is >___C and if there are rigors.
38.3
48
Where is the McBurney’s point?
approximately one-third of the way along a line originating at the anterior iliac spine and running to the umbilicus.
49
What are the signs in acute appendicitis ?
50
T/F
The presence of a fecalith is not diagnostic of appendicitis, although its presence in an appropriate location where the patient complains of pain is suggestive and is associated with a greater likelihood of complications.
True
51
CT scan findings suggestive of acute appendicitis
Suggestive findings on CT examination include dilatation >6 mm with wall thickening, a lumen that does not fill with enteric contrast, and fatty tissue stranding or air surrounding the appendix, which suggests inflammation
52
most common extrauterine general surgical emergency observed during pregnancy.
acute appendicitis
53
Whenever the diagnosis of acute appendicitis is uncertain, it is prudent to observe the patient and repeat the abdominal examination over ___ h.
6-8
54
In patients with acute appendicitis Management of those who present with a mass representing a phlegmon or abscess can be more difficult. Such patients are best served by treatment with broad-spectrum antibiotics, drainage if there is an abscess >___ cm in diameter, and parenteral fluids and bowel rest if they appear to respond to conservative management. The appendix can then be more safely removed ____weeks later when inflammation has diminished.
3 cm
6-12
55
The most common postoperative complications are ____ and ____
fever and leukocytosis
Continuation of these findings beyond 5 days should raise concern for the presence of an intraabdominal abscess.
56
Over 90% of the cases of primary or spontaneous bacterial peritonitis occur in patients with ascites or hypoproteinemia ( < __- g/L).
<1
57
most common esophageal symptom
heartburn
58
most useful test for the evaluation of the proximal gastrointestinal tract
upper endoscopy
59
Hiatal hernia is a herniation of viscera, most commonly the ____
stomach
60
Four types of hiatal hernia are distinguished, with type ___ composing at least 95% of the overall total
type I, or sliding hiatal hernia,
61
How do you differentiate hiatal hernia II vs III vs IV
Type II, III, and IV hiatal hernias are all subtypes of paraesophageal hernia in which the herniation into the mediastinum includes a visceral structure other than the gastric cardia.
With type II and III paraesophageal hernias, the gastric fundus also herniates, with the distinction being that in type II, the gastroesophageal junction remains fixed at the hiatus, whereas type III is a combined sliding and paraesophageal hernia.
With type IV hiatal hernias, viscera other than the stomach herniate into the mediastinum, most commonly the colon.
62
When the esophageal lumen diameter is <__ mm, distal rings are usually associated with episodic solid food dysphagia and are called Schatzki rings.
13mm
63
Most common type of esophageal diverticula
Epiphrenic
64
Most common location of hypopharyngeal herniation
Kilian's triangle
weakness of the cricopharyngeus
65
The typical presentation of esophageal cancer is of ____ (symptoms)
progressive solid food dysphagia and weight loss
66
Achalasia is a rare disease caused by loss of ganglion cells within the esophageal ____ plexus, with a population incidence estimated to be 1–3 per 100,000 and presentation usually occurring between age 25 and 60 years.
Myenteric plexus
67
How is achalasia diagnosed?
via barium swallow or esophageal manometry
68
Prevention or cure for achalasia?
none
LES pressure can be reduced by pharmacologic therapy, pneumatic balloon dilation, or LES myotomy by means of submucosal endoscopy or laparoscopic surgery. Nitrates or calcium channel blockers are administered before eating but should be used with caution because of their effects on blood pressure. Botulinum toxin, injected into the LES under endoscopic guidance, inhibits acetylcholine release from nerve endings and improves dysphagia in about two-thirds of cases for at least 6 months. Sildenafil and alternative phosphodiesterase inhibitors effectively decrease LES pressure, but practicalities limit their clinical use in achalasia
The only durable therapies for achalasia are pneumatic dilation and LES myotomy
69
Radiographic appearance of DES
corkscrew esophagus
70
Three dominant mechanisms of esophagogastric junction incompetence are recognized
(1) transient LES relaxations (a vagovagal reflex in which LES relaxation is elicited by gastric distention), (2) LES hypotension, or (3) anatomic distortion of the esophagogastric junction inclusive of hiatal hernia
Transient LES relaxations account for ~90% of reflux in normal subjects or GERD patients without hiatal hernia, but patients with hiatal hernia have a more heterogeneous mechanistic profile.
71
endoscopic hallmark of GERD
Erosive esophagitis at the esophagogastric junction is the endoscopic hallmark of GERD but identified in only about one-third of patients with GERD
72
most severe histologic consequence of GERD is _________
Barrett’s metaplasia with the associated risk of esophageal adenocarcinoma, and the incidence of these lesions has increased, not decreased, in the era of potent acid suppression
73
T/F
the perceived frequency and severity of heartburn correlates well with the presence or severity of esophagitis.
False
correlates poorly
74
Endoscopically identfiied esopageal finding in eosinophilic esophagitis
The characteristic endoscopically identified esophageal findings include loss of vascular markings (edema), multiple esophageal rings, longitudinally oriented furrows, and whitish exudate
Histologic confirmation is made with the demonstration of esophageal mucosal eosinophilia (peak density ≥15 eosinophils per high-power field
E-E-E-E
Eosinophilic-Esophagitis-Exudates-Edema
75
Treatment for eosinophilic esophagitis
Primary therapy often starts with PPI therapy, which is effective at improving eosinophilic inflammation in 30–50% of patients. Additional first-line therapies include elimination diets or swallowed topical glucocorticoids.
Immunocompromised patients are treated with acyclovir (400 mg orally five times a day for 14–21 days), famciclovir (500 mg orally three times a day), or valacyclovir (1 g orally three times a day)
Systemic glucocorticoids are not generally recommended due to side effects and lack of proven benefit beyond that achieved with topical glucocorticoids.
Biologic therapies targeting allergic cytokine mediators including interleukin (IL) 4, IL-5, and IL-13 have shown promise in initial clinical trials.
Esophageal dilation is highly effective at relieving dysphagia in patients with fibrostenosis but does not address the underlying inflammatory process.
76
Common CD4 count of px with infectious esophagitis
Among AIDS patients, infectious esophagitis becomes more common as the CD4 count declines; cases are rare with a CD4 count >200 and common when <100.
Regardless of the infectious agent, odynophagia is a characteristic symptom of infectious esophagitis; dysphagia, chest pain, and hemorrhage are also common
77
Most common cause of infectious esophagitis
C. albicans
78
Treatment for candida esophagitis
Oral fluconazole (400 mg on the first day, followed by 200 mg daily) for 14–21 days is the preferred treatment.
refractory: Voriconazole, Posaconazole
Unable to swallow: IV echinocandn
79
Characteristic endoscpic finding of herpetic esophagitis
The characteristic endoscopic findings are vesicles and small, superficial ulcerations
Because herpes simplex infections are limited to squamous epithelium, biopsies from the ulcer margins are most likely to reveal the characteristic groundglass nuclei, eosinophilic Cowdry’s type A inclusion bodies, and giant cells.
Cowdry Type A of herpetic esophagitis is intraNUCLEAR while the inclusion bodies of CMV esophagitis is CYTOPLASMIC and/or nuclear
80
Treatment for herpetic esophagitis
Acyclovir (200 mg orally five times a day for 7–10 days) can be used for immunocompetent hosts, although the disease is typically self-limited after a 1- to 2-week period in such patients.
Immunocompromised patients are treated with acyclovir (400 mg orally five times a day for 14–21 days), famciclovir (500 mg orally three times a day), or valacyclovir (1 g orally three times a day).
In patients with severe odynophagia, intravenous acyclovir, 5 mg/kg every 8 h for 7–14 days, reduces this morbidity
81
Endoscopic findings of CMV esophagitis
Endoscopically, CMV lesions appear as large serpiginous ulcers in an otherwise normal mucosa, particularly in the distal esophagus.
Biopsies from the ulcer bases have the greatest diagnostic yield for finding the pathognomonic large nuclear or cytoplasmic inclusion bodies.
Note: CMV = LARGE serpiginous ulcers; Herpetic = SMALL punched out with vesicles
82
Treatment for CMV esophagitis
Treatment studies of CMV gastrointestinal disease have demonstrated effectiveness of both ganciclovir (5 mg/kg every 12 h IV) and valganciclovir (900 mg orally every 12 h). Therapy is continued until healing, which may take 3–6 weeks. Maintenance therapy may be needed for patients with relapsing disease.
83
most sensitive in detecting mediastinal air from esophageal perforation
Chest CT
84
Most common symptom of Mallory Weiss Tear
Hematemesis
85
Radiation exposure in excess of ____ c Gy has been associated with increased risk of esophageal stricture.
5000 cGy
86
In pill esophagitis The most common location for the pill to lodge is in the _____
mid-esophagus near the crossing of the aorta or carina
87
Definition of ulcers
Ulcers are defined as breaks in the mucosal surface **>5** mm in size, with depth to the **submucosa**
88
Most common risk factors for PUD
H. pylori and NSAIDs
89
Most common location of duodenal ulcer
DUs occur most often in the first portion of the duodenum (>95%), with ~90% located within 3 cm of the pylorus.
90
Characteristic of benign gastric ulcers
Benign GUs are most often found distal to the junction between the antrum and the acid secretory mucosa. Benign GUs are quite rare in the gastric fundus and are histologically similar to DUs. Benign GUs associated with H. pylori are also associated with antral gastritis.
In contrast, NSAID-related GUs are not accompanied by chronic active gastritis but may instead have evidence of a chemical gastropathy, typified by foveolar hyperplasia, edema of the lamina propria, and epithelial regeneration in the absence of H. pylori. Extension of smooth-muscle fibers into the upper portions of the mucosa, where they are not typically found, may also occura
91
Transmission of H.pylori
Feco-oral route
92
Typical pain pattern of duodenal ulcer
The typical pain pattern in DU occurs 90 min to 3 h after a meal and is frequently relieved by antacids or food. Pain that awakes the patient from sleep (between midnight and 3 a.m.) is the most discriminating symptom, with twothirds of DU patients describing this complaint
93
most frequent PE finding in px with gastric or duodenal ulcer
Epigastric tenderness is the most frequent finding in patients with GU or DU
94
Most common complication of PUD
GI bleeding
2nd most common : perforation
95
Diagnostic tests for H.pylori
96
H2 blocker that is associated with weak antiandrogenic effects
Cimetidine
97
The half-life of PPIs is ~__h
18 h
98
Serum gastrin levels return back to normal after how many weeks of PPI cessation?
1-2w
99
As with any agent that leads to significant hypochlorhydria, PPIs may interfere with absorption of drugs such as _______
ketoconazole, ampicillin, iron, and digoxin
100
Nutrient deficiencies implicated in long term PPI use
Long-term use of PPIs has also been implicated
in the development of iron, vitamin B12, and magnesium deficiency
* magnesium level usually checked after 1-2yrs
101
In what situation/s is vonoprazan probably superior to PPI in PUD?
Vonoprazan may be superior to PPIs when combined with antibiotics for the treatment of H. pylori, and this novel agent has been awarded Fast Track status by the FDA for the treatment of H. pylori in combination with both amoxicillin and clarithromycin and with amoxicillin alone
102
Most common toxicity noted with prostaglandin analogues for PUD
The most common toxicity noted with this drug is diarrhea (10–30% incidence).
103
The aim for initial eradication rates of H.pylori should be ___ %
85–90
104
Recommended therapies for H. pylori eradicatio
The regimen of a PPI, bismuth, tetracycline, and metronidazole combined with a PPI for 10 days is an FDA-approved treatment regimen.
105
Approach to selecting abx for H. pylori tx
106
Salvage tx for H.pylori
107
Non selective NSAID associated with lower likelihood of GI and CV toxicity
Several nonselective NSAIDs that are associated with a lower likelihood of GI and CV toxicity include naproxen and ibuprofen, although the beneficial effect may be eliminated if higher dosages of the agents are used
108
Guide to NSAID tx in px with PUD
109
Duration of tx in H. pylori positive px
Once an ulcer (GU or DU) is documented, the main issue at stake is whether H. pylori or an NSAID is involved. With H. pylor present, independent of the NSAID status, **triple therapy **is recommended for **14 days**, followed by continued **acid-suppressing drugs **(H2 receptor antagonist or PPIs) for a total of **4–6 weeks**.
110
When should you request for test for documenting H. pylori eradication after antibiotic tx?
H. pylori eradication should be documented 4 weeks after completing antibiotics
111
The test of choice for documenting eradication of H. pylori is the laboratory-based validated ______
monoclonal stool antigen test or a urea breath test (UBT)
The patient must be off antisecretory agents for at least 7 days when being tested for eradication of H. pylori with UBT or stool antigen
112
Location of gastric ulcer that has potential for malignancy
GUs, especially of the body and fundus, have the potential of being malignant. Multiple biopsies of a GU should be taken initially; even if these are negative for neoplasm, repeat endoscopy to document healing at 8–12 weeks should be performed, with biopsy if the ulcer is still present. About 70% of GUs eventually found to be malignant undergo significant (usually incomplete) healing
Fu-Bo- bad --> malignant potential
113
When do you consider gastric ulcer and duodenal ulcer refractory to therapy?
A GU that fails to heal after 12 weeks and a DU that does not heal after 8 weeks of therapy should be considered refractory
114
Among the surgical interventions for PUD, The procedure that provides the lowest rates of ulcer recurrence (1%) but has the highest complication rate is ______
vagotomy (truncal or selective) in combination with antrectomy
115
Condition that must have been excluded preop before employing surgical tx for PUD
ZES should have been excluded preoperatively due to risk of ulcer recurrence after surgery
116
Medical therapy for post op ucleration after surgical tx in PUD
Medical therapy with H2 blockers will heal postoperative ulceration in 70–90% of patients. The efficacy of PPIs has not been fully assessed in this group, but one may anticipate greater rates of ulcer healing compared to those obtained with H2 blocker
117
How do you differentite the 2 types of afferent loop syndrome?
The more common of the two is bacterial overgrowth in the afferent limb secondary to stasis. Patients may experience postprandial abdominal pain, bloating, and diarrhea with concomitant malabsorption of fats and vitamin B12. Cases refractory to antibiotics may require surgical revision of the loop.
The less common afferent loop syndrome can present with severe abdominal pain and bloating that occur 20–60 min after meals. Pain is often followed by nausea and vomiting of bile-containing material. The pain and bloating may improve after emesis.
The cause of this clinical picture is theorized to be incomplete drainage of bile and pancreatic secretions from an afferent loop that is partially obstructed
118
What is dumping syndrome?
Dumping syndrome consists of a series of vasomotor and GI signs and symptoms and occurs in patients who have undergone vagotomy and drainage (especially Billroth procedures).
119
What are the pathophysiology behind the 2 phases of dumping syndrome?
Early dumping takes place 15–30 min after meals and consists of crampy abdominal discomfort, nausea, diarrhea, belching, tachycardia, palpitations, diaphoresis, light-headedness, and, rarely, syncope. These signs and symptoms arise from the rapid emptying of hyperosmolar gastric contents into the small intestine, resulting in a fluid shift into the gut lumen with plasma volume contraction and acute intestinal distention. Release of vasoactive GI hormones (vasoactive intestinal polypeptide, neurotensin, motilin) is also theorized to play a role in early dumping.
The late phase of dumping typically occurs 90 min to 3 h after meals. Vasomotor symptoms (light-headedness, diaphoresis, palpitations, tachycardia, and syncope) predominate during this phase. This component of dumping is thought to be secondary to hypoglycemia from excessive insulin release.
120
Cornerstone of tx in px with dumping syndrome
Dietary modification is the cornerstone of therapy for patients with dumping syndrome. Small, multiple (six) meals devoid of simple carbohydrates coupled with elimination of liquids during meals is important.
Antidiarrheals and anticholinergic agents are complementary to diet.
121
Pathophysiology behind decreased Vit B12 after partial gastrectomy
This is usually not due to deficiency of IF, since a minimal amount of parietal cells (source of IF) is removed during antrectomy.
Reduced vitamin B12 may be due to competition for the vitamin by bacterial overgrowth or inability to split the vitamin from its protein-bound source due to hypochlorhydria
122
What other micronutrient deficiency aside from Vit b12 is associated with Billroth II gastsrojejunostomy?
Iron and Folic acid
Malabsorption of vitamin D and calcium resulting in osteoporosis and osteomalacia is common after partial gastrectomy and gastrojejunostomy (Billroth II)
Copper deficiency has also been reported in patients undergoing surgeries that bypass the duodenum, where copper is primarily absorbed
123
the driving force responsible for the clinical manifestations in ZES
Hypergastrinemia originating from an autonomous neoplasm
124
The most common clinical presentation for gastrinoma patients is ____
abdominal pain in the presence of acid peptic disorders.
Diarrhea, the next most common clinical manifestation, is found in up to 70% of patients
125
When should you suspect gastrinoma?
Clinical situations that should create suspicion of gastrinoma are ulcers in unusual locations (second part of the duodenum and beyond), ulcers refractory to standard medical therapy, ulcer recurrence after acid-reducing surgery, ulcers presenting with frank complications (bleeding, obstruction, and perforation), or ulcers in the absence of H. pylori or NSAID ingestion.
126
1st step in the evaluation of a px with suspected ZES
Obtain fasting gastrin level
Fasting gastrin levels obtained using a dependable assay are usually <150 pg/mL. A normal fasting gastrin, on two separate occasions, especially if the patient is on a PPI, virtually excludes this diagnosis. Virtually all gastrinoma patients will have a gastrin level >150–200 pg/mL
127
Indications for ordering fasting gastrin level
128
How long should PPI be stopped before requesting for fasting gastrin level?
The effect of the PPI on gastrin levels and acid secretion will linger several days after stopping the PPI; therefore, it should be stopped for a minimum of 7 days before testing
129
a pH <___ is suggestive of a gastrinoma
3
gas-three-noma
130
The most sensitive and specific gastrin provocative test for the diagnosis of gastrinoma is the ___
secretin study
131
Most sensitive imaging modality for detecting primary gastrinoma
EUS
132
In px with gastrinoma, Up to __% of patients have metastatic disease at diagnosis.
50
133
Treatment of choice for ZES
PPI
yInitial PPI doses tend to be higher than those used for treatment of GERD or PUD. The initial dose of omeprazole, lansoprazole, rabeprazole, or esomeprazole should be in the range of 60 mg in divided doses in a 24-h period.
When gastric acid analysis was more widely available, dosing was adjusted to achieve a BAO <10 meq/h (at the drug trough) in surgery-naive patients and to <5 meq/h in individuals who have previously undergone an acid-reducing operation
134
Predictors of poor outcome in px with gastrinoma
Poor outcome is seen in patients with shorter disease duration; female sex; older age at diagnosis; higher gastrin levels (>10,000 pg/mL); poor histologic differentiation; high proliferative index; large pancreatic primary tumors (>3 cm); metastatic disease to lymph nodes, liver, and bone; and Cushing’s syndrome. Rapid growth of hepatic metastases is also predictive of poor outcome.
135
Most common cause of gastritis
infectious
H. pylori
136
What are the phases of chronic gastritis?
The early phase of chronic gastritis is superficial gastritis. The inflammatory changes are limited to the lamina propria of the surface mucosa, with edema and cellular infiltrates separating intact gastric glands.
The next stage is atrophic gastritis. The inflammatory infiltrate extends deeper into the mucosa, with progressive distortion and destruction of the glands.
The final stage of chronic gastritis is gastric atrophy. Glandular structures are lost, and there is a paucity of inflammatory infiltrates. Endoscopically, the mucosa may be substantially thin, permitting clear visualization of the underlying blood vessels.
137
How do you differentiate Type A from Type B gastritis
Chronic gastritis is also classified according to the predominant site of involvement. Type A refers to the body-predominant form (autoimmune), and type B is the antral-predominant form (H. pylori–related). This classification is artificial in view of the difficulty in distinguishing between these two entities. The term AB gastritis has been used to refer to a mixed antral/body picture.
Antibodies to parietal cells have been detected in >90% of patients with pernicious anemia and in up to 50% of patients with type A gastritis but anti IF antibodies more specific than abs to parietal cells
Mnemonic
Type A = A-utoimmune, A-ntral sparing, A-nemia (pernicious), A-chlorrhydia, Anti-IF
Type B = B-acteria (H. pylori)
138
Which is the more common form of gastritis Type A or B?
B
139
How accurate is urine dipstick compared to serum in detecting conjugated hyperbilirubinemia
Almost 100% accurate
140
What should you consider if the Fractionate bilirubin is >15% direct bilirubin?
Dubin Johnson or Rotor
The defect in Dubin-Johnson syndrome is the presence of mutations in the gene for MRP2. These patients have altered excretion of bilirubin into the bile ducts. Rotor syndrome may represent a deficiency of the major hepatic drug reuptake transporters OATP1B1 and OATP1B3
141
Next step if there is isolated hyperbilirubinemia and <15% direct bilirubin
rule out hemolysis
if negative, consider Gilbert's syndrome
142
Next step if LFTs showed cholestatic pattern
Review drugs
Utz
143
Next step when LFT is cholestatic and ducts are not dilated
AMA
if stil engative, do ERCP/ liver biopsy
144
Next step when LFT is cholestatic and ducts are dilated
CT/MRCP/ERCP
145
Next step when LFTs showed hepatocellular pattern
See pic
145
Next step if LFT showed isolated ALP elevation
Fractionate ALP or get GGT or 5' nucleotidase
146
Striking elevations—that is, aminotransferases >1000 IU/L—occur almost exclusively in disorders associated with extensive hepatocellular injury such as ____ (3)
(1) viral hepatitis, (2) ischemic liver injury (prolonged hypotension or acute heart failure), or (3) toxin- or drug-induced liver injury
147
AST ALT ratio suggestive of alcoholic liver dse
An AST:ALT ratio >2:1 is suggestive, whereas a ratio >3:1 is highly suggestive, of alcoholic liver disease. The AST in alcoholic liver disease is rarely >300 IU/L, and the ALT is often normal. A low level of ALT in the serum is due to an alcohol-induced deficiency of pyridoxal phosphate
148
Patients over age 60 can have a mildly elevated alkaline phosphatase (1–1.5 times normal), whereas individuals with blood types ___ and ___ can have an elevation of the serum alkaline phosphatase after eating a fatty meal due to the influx of intestinal alkaline phosphatase into the blood
O and B
148
In hepatitis, albumin levels <__ g/dL should raise the possibility of chronic liver disease
3
149
Marked prolongation of the prothrombin time, >_ s above control and not corrected by parenteral vitamin K administration, is a poor prognostic sign in acute viral hepatitis and other acute and chronic liver diseases
5
150
gold standard for documenting the presence of steatorrhea
72-h collection for weight/volume and fecal fat determination
151
how is steatorrhea defined?
Steatorrhea, defined as increased stool fat excretion to >7% of dietary fat, is a common manifestation of malabsorption
Quantitatively, steatorrhea is defined as stool fat exceeding the normal 7 g/d; rapid-transit diarrhea may result in fecal fat up to 14 g/d; daily fecal fat averages 15–25 g with small-intestinal diseases and is often >32 g with pancreatic exocrine insufficiency.
152
Chronic mesenteric ischemia is secondary to multiple major visceral arterio-occlusive disease, with involvement of the ____artery most worrisome
SMA
153
Differentiate chronic vs acute mesenteric ischemia in terms of pathophysiology
CMI is the failure to achieve normal postprandial hyperemic intestinal blood flow. This occurs due to an imbalance between the supply and demand of oxygen metabolites to the intestinal tract similar to cardiac angina. CMI occurs due to significant atherosclerotic disease leading to the narrowing of the SMA and/or celiac artery origins.
AMI is the occurrence of an abrupt cessation of mesenteric blood flow, usually embolic or thrombotic in nature. Approximately 50% of AMI is due to embolus to the mid to distal SMA. Embolus etiology includes atrial fibrillation, recent myocardial infarction, soft atherosclerotic plaque, infective endocarditis, valvular heart disease, and recent cardiac or vascular catheterization
154
Collateral vessels within the colon meet at the splenic flexure and descending/sigmoid colon. These areas, which are inherently at risk for decreased blood flow, are known as _____ and _____
Griffiths’ point and Sudeck’s point
Griffith = splenic flexure
Sudeck = Descending/ Sigmoid
155
Acute intestinal ischemia remains one of the most challenging diagnoses. The mortality rate of AMI is >___%
50
The most significant indicator of survival is the timeliness of diagnosis and treatment.
156
Most common chief complaint of acute mesenteric ischemia
Severe, acute, unremitting abdominal pain strikingly out of proportion to the physical findings is the most common complaint (95%). This may be associated with nausea (44%), vomiting (35%), diarrhea (35%), and blood per rectum (16%)
157
How do you manage acute intestinal ischemia
satients with AMI should be given a heparin bolus and started on a therapeutic heparin drip. Correction of electrolyte abnormalities and empiric broadspectrum antibiotic therapy should also be initiated immediately
If the CTA verifies the acute embolic occlusion of SMA, surgical exploration should not be delayed. The goal of operative exploration is to resect the compromised bowel and restore blood supply
Nonviable bowel should be resected. Questionable bowel should undergo a second-look laparotomy in a 24- to 48-h period
158
How do you diagnose acute intestinal ischemia
In patients with suspected AMI, CT angiography with a 1-mm or thinner cut should be used to detect mesenteric arterial occlusive disease most likely due to embolic or thrombotic etiology and is the gold standard
159
Most commonly affected part of volvulus
Sigmoid
160
Most common precursor for bowel strangulation
Closed loop obstruction
161
What should be ruled out when patient with acute intestinal obstruction presents with fever?
Fever is worrisome for strangulation or systemic inflammation
162
T/F
In patients with acute intestinal obstruction, Higher white blood cell counts with the presence of immature forms or the presence of metabolic acidosis are worrisome for severe volume depletion or ischemic necrosis and sepsis
True
163
A “staircasing” pattern of dilated air and fluid-filled small-bowel loops >___ cm in diameter with little or no air seen in the colon are classical findings in patients with small-bowel obstruction, although findings may be equivocal in some patients with documented disease
2.5
164
In px with small bowel obstrutcionPatients who have evidence of contrast appearing within the cecum within ___h of oral administration of water-soluble contrast can be expected to improve with high sensitivity and specificity (~95% each)
4-24h
165
T/F
Barium studies are generally contraindicated in patients with firm evidence of complete or high-grade bowel obstruction, especially when they present acutely.
True
166
When administering neostigmine, what medication should be readily available?
Cardiac monitoring is required, and atropine should be immediately available. Intravenous administration induces defecation and flatus within 10 min in the majority of patients who will respond
167
The most common site of intestinal obstruction in patients with gallstone “ileus” is the ____
ileum (60% of patients)
168
Early postoperative mechanical bowel obstruction is that which occurs within the first __ weeks of operation
6
169
_____ is the most common and most characteristic symptom of liver disease
Fatigue
170
RUQ pain or liver pain is due to ____
The pain arises from stretching or irritation of Glisson’s capsule, which surrounds the liver and is rich in nerve endings
171
hallmark symptom of liver disease and perhaps the most reliable marker of severity
Jaundice
172
single most common risk factor for hepatitis C
Injection drug use
173
blood transfusions received before the introduction of sensitive enzyme immunoassays for antibody to hepatitis C virus in year ___ is an important risk factor for chronic hepatitis C
1992
174
Blood transfusion before ___, when screening for antibody to hepatitis B core antigen was introduced, is also a risk factor for hepatitis B
1986
19Bb
175
Hepatitis E infection can become chronic in ______ patients in whom it presents with abnormal serum enzymes in the absence of markers of hepatitis B or C.
immunosuppressed individuals (such as transplant recipients, patients receiving chemotherapy, or patients with HIV infection),
176
. Alcohol consumption associated with an increased rate of alcoholic liver disease is probably more than ___ drinks per day in women and ____ drinks in men
2 (22–30 g)
3 (33–45 g)
177
What constitutes the CAGE questionnaire?
a One “yes” response should raise suspicion of an alcohol use problem, and more than one is a strong indication of abuse or dependence.
178
__________ refers to the slightly sweet, ammoniacal odor that can develop in patients with liver failure, particularly if there is portal-venous shunting of blood around the liver.
Fetor hepaticus
179
A helpful measure of hepatic encephalopathy is a careful mental status examination and use of the ___________ test
trail-making test
consists of a series of 25 numbered circles that the patient is asked to connect as rapidly as possible using a pencil.
The normal range for the connectthe-dot test is 15–30 s; it is considerably longer in patients with early hepatic encephalopathy
180
Triad of hepatopulmonary syndrome
liver disease, hypoxemia, and pulmonary arteriovenous shunting
The hepatopulmonary syndrome is characterized by platypnea and orthodeoxia: shortness of breath and oxygen desaturation that occur paradoxically upon the assumption of an upright position.
Measurement of oxygen saturation by pulse oximetry is a reliable screening test for hepatopulmonary syndrome.
181
Most common cause of chronic liver disease
The most common causes of chronic liver disease, in general order of frequency, are chronic hepatitis C, alcoholic liver disease, nonalcoholic steatohepatitis, chronic hepatitis B, autoimmune hepatitis, sclerosing cholangitis, primary biliary cholangitis, hemochromatosis, and Wilson disease
C- for chronic
182
Duration of chronic liver dse
> 6months
183
What constitutes child pugh scoring system
The Child-Pugh score is a reasonably reliable predictor of survival in many liver diseases and predicts the likelihood of major complications of cirrhosis, such as bleeding from varices and spontaneous bacterial peritonitis
184
With regard to vaccinations, all patients with liver disease should receive ____ vaccine, and those with risk factors should receive ____ vaccine as well.
hepatitis A
hepatitis B
185
The CDC now recommends universal one-time testing for hepatitis C virus among persons aged _____ years and screening of all pregnant women during each pregnancy except in settings where the prevalence of hepatitis C virus infection (hepatitis C virus RNA positivity) is <___%.
18–79
0.1%
186
When should ultrasound of the liver be done for px with liver cirrhosis
While the optimal regimen for such surveillance has not been established, an appropriate approach is US of the liver at 6- to 12-month interval
187
Most commonly involved part in divericulosis
descending and sigmoid colon except in asians in which right sided diverticulosis are more common
188
Hemorrhage from a _____ is the most common cause of hematochezia in patients >60 years
colonic diverticulum
yet only 20% of patients with diverticulosis will have gastrointestinal bleeding.
189
Colonic wall thickness suggestive of diverticulitis on CT scan
> 4mm
190
Most common presentation of diverticular dse
uncomplicated - abdominal pain
191
A colonoscopy should be performed ~___weeks after an attack of diverticular disease.
6
The parallel epidemiology of colorectal cancer and diverticular disease provides enough concern for an endoscopic evaluation before operative management.
Although the benefit of colonoscopy in the evaluation of patients with diverticular disease has been called into question, its use is still considered important in the exclusion of colorectal cancer
192
Required amount of fiber in diverticulosis
30g
193
Established risk factors for acute diverticulitis for symptomatic recurrence include _____
younger age, the formation of a diverticular abscess, more frequent attacks (>2 per year), multimorbidity, obesity, and smoking.
194
When should you operate on acute diverticulitis?
If the patient is unstable or has had a 6-unit bleed within 24 h, current recommendations are that surgery should be performed
195
Is mesalazine beneficial in acute uncomplicated diverticulitis?
The use of anti-inflammatory medications (mesalazine) in randomized clinical trials has shown them to be beneficial at reducing symptoms and disease recurrence in patients with SUDD. However, when objective signs of inflammation such as C-reactive protein and computerized imaging are taken into consideration, no benefit for the use of mesalazine has been shown
196
What poorly absorbed antibiotic may also lessed frequent recurrence of symptoms of uncomplicated diverticular disease
Rifaximin (a poorly absorbed broad-spectrum antibiotic), when compared to fiber alone for the treatment of SUDD, is associated with 30% less frequent recurrent symptoms from uncomplicated diverticular disease.
197
What trial demonstrated that elective surgical resection was associated with an improved quality of life and was more cost-effective at 5 years following resection as compared to conservative management in px with acute uncomplicated diverticulitis?
A multicentered randomized clinical trial (DIRECT trial) comparing surgery with conservative management for recurrent SUDD demonstrated that elective surgical resection was associated with an improved quality of life and was more cost-effective at 5 years following resection as compared to conservative management.
198
What is the surgical therapy for each Hinchey classification?
Patients with Hinchey stage Ia are managed with antibiotic therapy only followed by resection with anastomosis at 6 weeks.
Patients with Hinchey stages Ib and II disease are managed with percutaneous drainage followed by resection with anastomosis about 6 weeks later.
Current guidelines put forth by the American Society of Colon and Rectal Surgeons suggest, in addition to antibiotic therapy, CT-guided percutaneous drainage of diverticular abscesses that are >3 cm and have a well-defined wall. Abscesses that are <5 cm may resolve with antibiotic therapy alone
No anastomosis of any type should be attempted in Hinchey stage IV disease or in the presence of fecal peritonitis
199
The incidence of rectal prolapse peaks in women >___ years.
60
200
Staging of internal hemorrhoids
201
With rare exceptions, the acutely thrombosed hemorrhoid can be excised within the first __h
72h
202
Most common type of fistula in ano
70% being intersphincteric, 23% transsphincteric, 5% suprasphincteric, and 2% extrasphincteric
203
The most common pancreatic cyst type encountered is an/ a___________ , which is classified as a precancerous mucinous cyst.
intraductal papillary mucinous neoplasm (IPMN)
In the absence of high-risk features, radiographic surveillance is typically recommended
204
In acute pancreatitis, the serum amylase and lipase are usually elevated within ___ of onset and remain so for _____.
24h
3–7 days
205
What 4 steps constitute the stepwise diagnostic approach to the patient with suspected chronic pancreatitis
206
best imaging study for the assessment of complications of acute and chronic pancreatitis
CT scan with IV contrast
207
The major benefit of CT scan in acute pancreatitis is
the diagnosis of pancreatic necrosis in patients not responding to conservative management within 72 h
It may take 48–72 h to develop perfusion defects indicative of pancreatic necrosis.
208
When should you perform EUS in px with acute pancreatitis?
EUS is not beneficial for the evaluation of pancreas during acute pancreatitis. It is preferable to perform EUS after the resolution of acute pancreatitis (**~4 weeks**) to detect any predisposing factors, including malignancy, choledocholithiasis, pancreatic divisum, or ampullary lesions
209
most sensitive modality for the detection of bile duct stones
ERCP
210
The most reproducible measurement, giving the highest level of discrimination between normal subjects and patients with chronic pancreas dysfunction, appears to be the _____
maximal bicarbonate concentration
after direct stimulation by secretin
211
Decreased ____activity in stool is a test to detect severe exocrine pancreatic insufficiency (EPI) in patients with chronic pancreatitis and cystic fibrosis.
fecal elastase-1 (FE-1)
FE-1 levels >200 μg/g are normal, levels of 100–200 μg/g are considered mild-moderate EPI, and levels <100 μg/g are severe EPI
212
leading cause of acute pancreatitis
gallstones
Alcohol is the second most common cause, responsible for 15–30% of cases in the United States
213
A faint blue discoloration around the umbilicus (______ sign) may occur as the result of hemoperitoneum, and a blue-red-purple or greenbrown discoloration of the flanks (____ sign) reflects tissue breakdown of hemoglobin from severe necrotizing pancreatitis with hemorrhage
Cullen’s (C for Center)
Turner’s (T for tabi)
214
Effect of arterial pH on serum amylase
Importantly, patients with acidemia (arterial pH ≤7.32) may have spurious elevations in serum amylase
This finding explains why patients with diabetic ketoacidosis may have marked elevations in serum amylase without any other evidence of acute pancreatitis.
A-A
Acid-Amylase
215
how do you define the different morphologic features of pancreatitis?
216
Electrolyte abnormality assoc with acute panc
Hypocalcemia occurs in ~25% of patients, and its pathogenesis is incompletely understood
217
most important clinical finding regarding severity of the acute pancreatitis episode.
Persistent organ failure (>48 h)
if present, severe na agad
218
The radiographic feature of greatest importance to recognize in the late phase of acute panc is _____
development of necrotizing pancreatitis on CT imaging.
219
In mild acute pancreatitis, the disease is self-limited and subsides spontaneously, usually within ___ days after onset.
3-7
220
most important treatment intervention for acute pancreatitis
early, aggressive intravenous fluid resuscitation to prevent systemic complications from the secondary systemic inflammatory response.
221
Rate of IV infusion in px with acute pancreatitis
Intravenous fluids of lactated Ringer’s or normal saline are initially bolused at 15–20 mL/kg (1050–1400 mL), followed by 2–3 mL/kg per hour (200–250 mL/h), to maintain urine output >0.5 mL/kg per hour.
Serial bedside evaluations are required every 6–8 h to assess vital signs, oxygen saturation, and change in physical examination to optimize fluid resuscitation
222
In px with acute panc, a rise in hematocrit or BUN during serial measurement should be treated with
a repeat volume challenge with a *2-L *crystalloid bolus followed by increasing the fluid rate by ** 1.5 mg/kg** per hour
223
What constitutes BISAP
The Bedside Index of Severity in Acute Pancreatitis (BISAP) incorporates five clinical and laboratory parameters obtained within the first 24 h of hospitalization—BUN >25 mg/dL, impaired mental status (Glasgow coma scale score <15), SIRS, age >60 years, and pleural effusion on radiography—that can be useful in assessing severity
224
What factors in acute panc is associated with increased rsk fo in hospital mortality
The presence of three or more of these factors (BISAP) was associated with substantially increased risk for in-hospital mortality among patients with acute pancreatitis.
In addition, an elevated hematocrit >44% and admission BUN >22 mg/dL are also associated with more severe acute pancreatitis
225
Patients with evidence of ascending cholangitis (rising white blood cell count, increasing liver enzymes) should undergo ERCP within ____ (duration) of admission.
24–48 h
226
Serum triglycerides >___ mg/dL are associated with acute pancreatitis
1000
227
most common presenting symptoms of autoimmune panc
Jaundice, weight loss, and new-onset diabetes
228
treatment for autoimmune pancreatitis
Patients typically respond dramatically to glucocorticoid therapy within a 2- to 4-week period. Prednisone is usually administered at an initial dose of 40 mg/d for 4 weeks followed by a taper of the daily dosage by 5 mg per week based on monitoring of clinical parameters
229
The secretin test becomes abnormal when ≥___% of the pancreatic exocrine function has been lost
60
230
Treatment for exocrine pancreatic insufficiency
For adult patients with exocrine pancreatic insufficiency, it is generally recommended to start at a dosage of 25,000–50,000 units of lipase taken during each meal; however, the dose may need to be increased up to 100,000 units of lipase depending on the response in symptoms, nutritional parameters, and/or pancreas function test results.
Additionally, some may require acid suppression with proton pump inhibitors to optimize the response to pancreatic enzymes. Monitoring nutritional parameters such as fat-soluble vitamins, zinc levels, body weight, and periodic bone mineral density measurement should be considered.
231
Hereditary pancreatitis (PRSS1) is a rare form of pancreatitis with early age of onset that is typically associated with familial aggregation of cases. A genome-wide search using genetic linkage analysis identified the hereditary pancreatitis gene on chromosome __
7
232
Definition of binge drinking
4 drinks for women and 5 drinks for men in ~2 h (1 drink equals ~14 g of ethanol, which
is 1 beer, 4 oz of wine, or 1 oz of 80% spirits)
233
Factors for Progression of Alcohol-Associated Liver Disease
234
Patients with alcoholic hepatitis have been drinking heavily for typically >___ years and until at least __ weeks before onset of symptoms
5
8
235
Patients with alcoholic hepatitis have AST and ALT elevations that do not exceed ___ IU/L, with AST/ALT ratio of >1.5 and serum bilirubin >__ mg/dl
400
3
236
Liver stiffness <6 kPa indicates normal liver, whereas cutoffs for each stage of alcohol-associated liver fibrosis have been validated (>__ kPa indicates ≥F3 advanced fibrosis; >__ kPa indicates F4 cirrhosis).
8
12.5
237
Patients with MDF <___ or MELD ≤___ are defined as having moderate alcoholic hepatitis
32 (Dirty 2; sounds like 32 ) Dirty living coz alcoholic
20
238
Treatment for severe alcoholic hepatitis
Glucocorticoid use reduces the risk of death in patients with severe alcoholic hepatitis within 28 days of treatment but not in the following 6 months. Oral prednisolone, 40 mg/d for a total duration of 4 weeks, is preferred. For patients unable to take oral medications, methylprednisolone, 32 mg/d IV, is used. The combination of glucocorticoids with N-acetylcysteine infusion might add short-term survival benefit at 1 month
Failure of improvement of Lille score (≥0.45) after 7 days of glucocorticoid treatment will determine patients with severe alcoholic hepatitis who will unlikely benefit from continued treatment with glucocorticoids.
239
How do you diagnose NAFLD?
Diagnosing NAFLD requires demonstration of increased liver fat in the absence of hazardous levels of alcohol consumption
240
gold standard for establishing the severity of liver injury and fibrosis
Liver biopsy has been the gold standard for establishing the severity of liver injury and fibrosis because it is both more sensitive and more specific than these other tests for establishing NAFLD severity
241
FDA approved tx for NAFLD
None
242
OHAS that may be used in NASH px with T2DM or obesity
Both incretin mimetics and SGLT2 inhibitors can be used in NASH patients with type 2 diabetes or obesity (conditions for which the drugs have an FDA-registered indication for use); however, they are not currently approved specifically for the treatment of NASH.
243
Drug/ supplement that may be used as first line for non DM non cirrhotic NASH patients
vitamin E should only be considered as a first-line pharmacotherapy for nondiabetic, noncirrhotic NASH patients who are at low risk for cardiovascular disease or prostate cancer.
244
T/F
There is no evidence to suggest that statins cause liver failure in patients with any chronic liver disease, including NAFLD
True
245
Most impt mechanism of gallstone formation
The most important is increased biliary secretion of cholesterol.
246
rate-limiting enzyme of hepatic cholesterol synthesis
(HMG-CoA) reductase
247
Pigment stones are more commonly seen in which subsets of patients
They are more common in patients who have chronic hemolytic states (with increased conjugated bilirubin in bile); cirrhosis, especially related to alcohol; Gilbert’s syndrome; or cystic fibrosis
248
most specific and characteristic symptom of gallstone disease
biliary colic
Biliary colic begins quite suddenly and may persist with severe intensity for 30 min to 5 h, subsiding gradually or rapidly
An episode of biliary pain persisting beyond 5 h should raise the suspicion of acute cholecystitis
249
Patients with very large gallstones (>__ cm in diameter) and patients harboring gallstones in a congenitally anomalous gallbladder might also be considered for prophylactic cholecystectomy
3
250
Dose of UDCA for stone dissolution
The dose of UDCA should be 10–15 mg/kg per day
In carefully selected patients with a functioning gallbladder and with radiolucent stones <10 mm in diameter, complete dissolution can be achieved in ~50% of patients within 6 months to 2 years
251
Most commonly isolated organisms in acute cholecystitis
The organisms most frequently isolated by culture of gallbladder bile in these patients include Escherichia coli, Klebsiella spp., Streptococcus spp., and Clostridium spp
252
Imaging modality that may be used as confirmatory test for acute cholecystitis
The radionuclide (e.g., HIDA) biliary scan may be confirmatory if bile duct imaging is seen without visualization of the gallbladder
253
rare complication in which a gallstone becomes impacted in the cystic duct or neck of the gallbladder causing compression of the CBD, resulting in CBD obstruction and jaundice
Mirizzi's syndrome
254
Organisms commonly isolated in emphysematous cholecystitis
Bacteria most frequently cultured in this setting include anaerobes, such as Clostridium welchii or C. perfringens, and aerobes, such as E. coli
255
Patients with uncomplicated acute cholecystitis should undergo early elective laparoscopic cholecystectomy, ideally within ____ h after diagnosis
48-72
256
the presence of a palpably enlarged gallbladder suggests that the biliary obstruction is secondary to an underlying malignancy rather than to calculous disease is based on what law
Courvoisier’s law
257
CBD stones should be suspected in any patient with cholecystitis whose serum bilirubin level is >_____
85.5 μmol/L (5 mg/dL)
Serum bilirubin levels ≥342.0 μmol/L (20 mg/dL) should suggest the possibility of neoplastic obstruction
258
Initial tx of choice for IgG4 asssociated cholangitis
Glucocorticoids
259
Tx for primary sclerosing cholangitis
There is no proven medical therapy for PSC. Therapy to treat pruritus associated with PSC includes cholestyramine, rifampin, and naltrexone. Antibiotics are useful when bacterial cholangitis complicates the clinical picture. Vitamin D and calcium supplementation may be used as initial therapy to help prevent the loss of bone mass frequently seen in patients with chronic cholestasis.
260
A unique form of hemolytic anemia (with spur cells and acanthocytes) called ____ syndrome can occur in patients with severe alcoholic hepatitis
Zieve’s
261
treatment of choice for patients with decompensated cirrhosis due to Primary biliary cholangitis
liver transplant
Ursodeoxycholic acid (UDCA) is the first-line treatment that has some degree of efficacy by slowing the rate of progression of the disease
262
______ antibodies are present in ~95% of patients with Primary biliary cholangitis
Antimitochondrial (AMA)
263
Pruritus from Primary biliary cholangitis is treatmed with _________
Pruritus is treated with antihistamines, narcotic receptor antagonists (naltrexone), and rifampin.
264
One autoantibody, the _____ , is positive in ~65% of patients with PSC
perinuclear antineutrophil cytoplasmic antibody (pANCA)
265
Definitive dx for primary sclerosing cholangitis
The definitive diagnosis of PSC requires cholangiographic imaging.
266
treatment of choice for patients with decompensated cirrhosis due to Primary sclerosing cholangitis
also liver transplant
A dreaded complication of PSC is the development of cholangiocarcinoma, which is a relative contraindication to liver transplantation.
unlike it PBC, A study of high-dose (28–30 mg/kg per d) UDCA found it to be harmful
267
Portal hypertension is defined as the elevation of the hepatic venous pressure gradient (HVPG) to >____
5 mmHg
There is usually an initial stage of compensated cirrhosis with HVPG between 5 and 10 mmHg that can be asymptomatic and last for ≥10 years, but when clinically significant portal hypertension develops (HVPG ≥10 mmHg), there is substantial risk of decompensation with variceal bleeding, ascites, or hepatic encephalopathy
268
. Cardiac ascites can be identified by SAAG >___ g/dL and ascites protein >____g/dL
> 1.1
> 2.5
When the SAAG is <1.1 g/dL, infectious or malignant causes of ascites should be considered. When ascitic fluid protein is very low, <1.5 g/dL, patients are at increased risk for developing SBP
269
Max dose of furo and spirono for ascites
maximum of 160 mg/d furosemide to 400 mg/d of spironolactone
270
After LVP of ≥5 L, IV 25% albumin at a dose of ~_ g/L of removed ascites should be given to prevent circulatory dysfunction.
8
Patients undergoing LVP should receive IV albumin infusions of 6–8 g/L of ascitic fluid removed.
271
Complication associated with TIPS
TIPS is often associated with an increased frequency of hepatic encephalopathy
In patients who develop azotemia in the course of receiving diuretics in the management of their ascites, some will require repeated large-volume paracentesis (LVP), some may be considered for transjugular intrahepatic portosystemic shunt (TIPS), and some would be good candidates for liver transplantation.
272
Presumed mechanism for the development of SBP
Bacterial translocation is the presumed mechanism for development of SBP, with gut flora traversing the intestine into mesenteric lymph nodes, leading to bacteremia and seeding of the ascitic fluid
273
Most common organisms assoc with SBP
The most common organisms are Escherichia coli and other gut bacteria; however, gram-positive bacteria, including Streptococcus viridans, Staphylococcus aureus, and Enterococcus spp., can also be found
If more than two organisms are identified, secondary bacterial peritonitis due to a perforated viscus should be considered.
274
How do you diagnose SBP?
The diagnosis of SBP is made when the fluid sample has an absolute neutrophil count >250/μL
275
Treatment for SBP
Treatment is commonly with intravenous third-generation cephalosporin for 5 days.
In addition, intravenous albumin (1.5 g/kg body weight on day and 1.0 g/kg on day 3) has been shown to reduce the risk of renal failure and to improve survival.
276
What is the antibiotic prophylaxis of choice to prevent recurrent SBP
In patients with variceal hemorrhage, the frequency of SBP is significantly increased, and prophylaxis against SBP is recommended when a patient presents with upper GI bleeding. Furthermore, in patients who have had an episode (or multiple episodes) of SBP and recovered, quinolone antibiotic prophylaxis should be given to prevent recurrent SBP
277
The best therapy for HRS is _______
liver transplantation
278
Mainstay treatment for hepatic encephalopathy
lactulose, a nonabsorbable disaccharide, which results in colonic acidification
The goal of lactulose therapy is to promote two to three soft stools per day.
More recently, rifaximin at 550 mg twice daily has been very effective in preventing recurrent encephalopathy
279
Recommended kcal and protein in px with cirrhosis
General recommendations include multiple small meals including a late evening snack with total calories of 25–30 kcal per kg of ideal body weight per day and 1.2–1.5 g of protein per kg of ideal body weight per day
280
Among patients with acute liver failure, ______ is the most common cause
drug-induced liver injury (DILI)
281
Liver morphology associated with DILI caused by acetaminophen
282
Liver morphology associated with DILI caused by co-amoxiclav
283
Liver morphology associated with DILI caused ciprofloxacin
Same with isoniazid
284
Liver morphology associated with DILI caused by Carbon tetrachloride
285
Liver morphology associated with DILI caused by estrogen
286
Treatment for toxic/drug induced hepatic dse
Treatment is largely supportive, except in acetaminophen hepatotoxicity (for which N-acetylcysteine is effective
286
Fatal fulminant disease is usually (although not invariably) associated with ingestion of ≥__ of acetaminophen.
25 g
287
Blood levels of acetaminophen correlate with severity of hepatic injury (levels >___ μg/mL 4 h after ingestion are predictive of the development of severe damage; levels <___μg/mL suggest that hepatic injury is highly unlikely).
300
150
Nausea, vomiting, diarrhea, abdominal pain, and shock are early manifestations occurring 4–12 h after ingestion. Then 24–48 h later, when these features are abating, hepatic injury becomes apparent. Maximal abnormalities and hepatic failure are evident 3–5 days after ingestion, and aminotransferase levels exceeding 10,000 IU/L are not uncommon
288
in chronic alcoholics, the toxic dose of acetaminophen may be as low as __ g, and alcoholic patients should be warned specifically about the dangers of even standard doses of this commonly used drug
2
289
Dose of NAC for acetaminophen toxicity
Routine use of N-acetylcysteine has substantially reduced the occurrence of fatal acetaminophen hepatotoxicity. N-acetylcysteine may be given orally but is more commonly used as an IV solution, with a loading dose of 140 mg/kg over 1 h, followed by 70 mg/kg every 4 h for 15–20 doses.
treatment can be stopped when plasma acetaminophen levels indicate that the risk of liver damage is low.
290
What constitutes the Rome IV criteria for IBS?
pain is a key symptom for the
diagnosis of IBS.
1-2-3
1day per week
2 ssx
3 months
291
most consistent clinical feature in IBS.
Alteration in bowel habits
The most common pattern is constipation alternating with diarrhea, usually with one of these symptoms predominating.
292
Organisms implicated in post infectious IBS
The microbes involved in the initial infection are Campylobacter, Salmonella, and Shigella
293
T/F
Nocturnal diarrhea may be a presentation of IBS
False
294
In patients with persistent diarrhea not responding to simple antidiarrheal agents, a _____ should be performed to rule out microscopic colitis.
sigmoid colon biopsy
In those age >40 years, an air-contrast barium enema or colonoscopy should also be performed
295
Treatment for IBS-diarrhea
When diarrhea is severe, especially in the painless diarrhea variant of IBS, small doses of loperamide, 2–4 mg every 4–6 h up to a maximum of 12 mg/d, can be prescribed.
296
Antibiotic that may be effective in IBS px
Neomycin and Rifaximin
Rifaximin is the only antibiotic with demonstrated sustained benefit beyond therapy cessation in IBS patients
297
Treatment for IBS
298
Risk factors for IBD
strongest risk factor for the development of IBD is a first-degree relative with the disease
yung mga may protective is for UC
299
Rectum is spared in UC or CD?
CD
Unlike UC, which almost always involves the rectum, the rectum is often spared in CD
300
earliest lesions in chron's dse
aphthoid ulcerations and focal crypt abscesses with loose aggregations of macrophages, which form noncaseating in all layers of the bowel wall
301
Fecal acute phase reactants used in the management of IBD
Fecal lactoferrin, a glycoprotein present in activated neutrophils, is a highly sensitive and specific marker for detecting intestinal inflammation.
Fecal calprotectin is present in neutrophils and monocytes, and levels correlate well with histologic inflammation, predict relapses, and detect pouchitis.
Both fecal lactoferrin and calprotectin are becoming an integral part of IBD management and are used frequently to rule out active inflammation versus symptoms of irritable bowel or bacterial overgrowth
Fecal calprotectin is a more sensitive marker of ileocolonic or colonic inflammation rather than isolated ileal inflammation.
302
Toxic megacolon is defined as a transverse or right colon with a diameter of >__ cm, with loss of haustration in patients with severe attacks of UC.
6
303
Most common site of inflammation in Chron's dse
Ileum
Because the most common site of inflammation is the terminal ileum, the usual presentation of ileocolitis is a chronic history of recurrent episodes of right lower quadrant pain and diarrhea
304
Treatment of choice for abscess associated with Chron's dse
CT-guided percutaneous drainage of the abscess is standard therapy.
305
Autoantibodies associated with CD and UC
Increased titers of anti–Saccharomyces cerevisiae antibody (ASCA) have been associated with CD, whereas increased levels of perinuclear antineutrophil cytoplasmic antibody (pANCA) are more commonly seen in patients with UC
mnemonic pUnCa --> UC = pANCA
306
What treatment for IBD is associated with paradoxical worsening of colitis?
5-ASA eg. sulfasalazine, mesalamine
307
Dose of glucocorticoids for IBD
The majority of patients with moderate to severe UC benefit from oral or IV glucocorticoids.
Prednisone is usually started at doses of 40–60 mg/d for active UC that is unresponsive to 5-ASA therapy. Parenteral glucocorticoids may be administered as hydrocortisone, 300 mg/d, or methylprednisolone, 40–60 mg/d
Glucocorticoids are also effective for treatment of moderate to severe CD and induce a 60–70% remission rate compared to a 30% placebo response
308
Treatment for IBD that is/are associated with acute pancreatitis
Although azathioprine and Mercaptopurine are usually safe, pancreatitis occurs in 3–4% of patients, typically presents within the first few weeks of therapy, and is completely reversible when the drug is stopped
The toxicity of these drugs may be further increased in px who lack thiopurine methyltransferase
309
The highest risk for thiopurine-associated lymphoma is in patients >___years old actively using thiopurines
65
310
High-risk patients with CD who are more likely to require biologics include those who are ________
**<30 **years old, with extensive disease, perianal or severe rectal disease and/or deep ulcerations in the colon, and stricturing or penetrating disease behavior
311
Treatment for IBD associated with inc risk of melanoma
Anti-TNF tx
Also assoc with risk of new onset psoriaform skin lesions
312
Before starting anti TNF tx for IBD, these tests should be requested
Patients should have a purified protein derivative (PPD) or a QuantiFERON-TB Gold test before initiation of anti-TNF therapy.
Hep B testing
Additional test for natalizumab: anti JCV since associated with PML
313
Indications for surgery in IBD
314
Treatment for IBD that may be used for pregnant px
Sulfasalazine and all mesalamines are safe for use in pregnancy and nursing with the caveat that additional folate supplementation must be given with sulfasalazine. Topical 5-ASA agents are safe during pregnancy and nursing. Glucocorticoids are generally safe for use during pregnancy and are indicated for patients with moderate to severe disease activity
The safest antibiotics to use for CD in pregnancy for short periods of time (weeks, not months) are ampicillin and cephalosporins. Metronidazole can be used in the second or third trimester
Mercaptopurine and azathioprine pose minimal or no risk during pregnancy
315
How long should methotrexate be discontinued before conception?
MTX is teratogenic and should be discontinued at least 3 months before conception
316
In px with IBD Annual or biennial colonoscopy with multiple biopsies is recommended for patients with >____ years of extensive colitis (greater than one-third of the colon involved) or ____ years of proctosigmoiditis (less than one-third but more than just the rectum) and has been widely used to screen and survey for subsequent dysplasia and carcinoma
8–10
12-15
317
The only non RNA virus among the hepatitis viruses
HBV
317
After a person is infected with HBV, the first virologic marker detectable in serum within 1–12 weeks, usually between 8 and 12 weeks, is ______
HBsAg
Circulating HBsAg precedes elevations of serum aminotransferase activity and clinical symptoms by 2–6 weeks and remains detectable during the entire icteric or symptomatic phase of acute hepatitis B and beyond
318
Why is there no HbcAg ?
Because HBcAg is intracellular and, when in the serum, sequestered within an HBsAg coat, naked core particles do not circulate in serum, and therefore, HBcAg is not detectable routinely in the serum of patients with HBV infection. By contrast, anti-HBc is readily demonstrable in serum, beginning within the first 1–2 weeks after the appearance of HBsAg and preceding detectable levels of anti-HBs by weeks to months
319
During the “gap” or “window” period of Hep B infection, ____ may represent the only serologic evidence of current or recent HBV infection
anti-HBc
320
The appearance of this serologic marker coincides temporally with high levels of virus replication and reflects the presence of circulating intact virions and detectable HBV DNA
HbeAg
321
During early chronic HBV infection, HBV DNA can be detected both in serum and in hepatocyte nuclei, where it is present in free or episomal form. This relatively highly replicative stage of HBV infection is the time of maximal infectivity and liver injury; ____ is a qualitative marker and ____ a quantitative marker of this replicative phase, during which all three forms of HBV circulate, including intact virions.
HbeAg
HBV DNA
322
Currently available, third-generation immunoassays, which incorporate proteins from the ______ regions , detect anti-HCV antibodies during acute infection
core, NS3, and NS5 regions
323
Which Hep virus has the histologic lesion that is often remarkable for a relative paucity of inflammation?
HCV
324
In hepatitis __, a common histologic feature is marked cholestasis
E
325
High-Risk Populations for Whom HBV Infection Screening Is Recommended
326
T/F
Breast-feeding does not increase the risk of HCV infection between an infected mother and her infan
True
327
High-Risk Populations for Whom HCV-Infection Screening Is Recommended
328
T/F
The titer of HBsAg bears is correlated to the severity of clinical disease
False
329
Principal usefulness of HbeAg
Its principal clinical usefulness is as an indicator of relative infectivity
330
A false-positive test for IgM anti-HBc may be encountered in patients with high-titers of _____ factor
rheumatoid factor
331
Assays for ____ are the most sensitive tests for HCV infection and represent the “gold standard” in establishing a diagnosis of hepatitis C
HCV RNA
HCV RNA can be detected even before acute elevation of aminotransferase activity and before the appearance of anti-HCV in patients with acute hepatitis C.
Determination of HCV RNA level is NOT a reliable marker of disease severity or prognosis but is helpful in predicting relative responsiveness to antiviral therapy.
332
Serology of Acute hepatitis B (HBsAg below detection threshold)
333
The most feared complication of viral hepatitis is ________________
is fulminant hepatitis (massive hepatic necrosis)
Fulminant hepatitis is seen primarily in hepatitis B, D, and E, but rare fulminant cases of hepatitis A occur primarily in older adults and in persons with underlying chronic liver disease, including, according to some reports, chronic hepatitis B and C
334
clinical and laboratory features suggest progression of acute hepatitis to chronic hepatitis
The following clinical and laboratory features suggest progression of acute hepatitis to chronic hepatitis: (1) lack of complete resolution of clinical symptoms of anorexia, weight loss, fatigue, and the persistence of hepatomegaly; (2) the presence of bridging/interface or multilobular hepatic necrosis on liver biopsy during protracted, severe acute viral hepatitis; (3) failure of the serum aminotransferase, bilirubin, and globulin levels to return to normal within 6–12 months after the acute illness; and (4) the persistence of HBeAg for >3 months or HBsAg for >6 months after acute hepatitis.
Hb3Ag,
HbsAg --> S for six months
335
After acute HCV infection, the likelihood of remaining chronically infected approaches ___ %
85-90
336
Among cirrhotic patients with chronic hepatitis C, the annual risk of hepatic decompensation is ___
~4%
337
The annual rate of hepatocellular carcinoma in patients with chronic hepatitis D and cirrhosis is ~___%
3%
338
For POSTexposure prophylaxis of intimate contacts (household, sexual, institutional) of persons with hepatitis A, the administration of ___ mL/kg is recommended as early after exposure as possible; it may be effective even when administered as late as __ weeks after exposure
0.02
2
339
For hepatitis A, A vaccination, PRExposure prophylaxis for travel consists of IG at doses of ___ mg/kg for travel durations up to 1 month, ___ mg/kg for travel up to 2 months, and repeat 0.2 mg/kg every 2 months thereafter for the remainder of travel
0.1
0.2
However, for travel to an endemic area, hepatitis A vaccine NOT Ig is the preferred approach to preexposure immunoprophylaxis and provides long-lasting protection (protective levels of anti-HAV should last at least 20 years after vaccination)
340
HAV vaccination schedule
0,6-12
341
HBV vaccination schedule
342
For perinatal exposure of infants born to HBsAg-positive mothers, a single dose of HBIG, ___ mL, should be administered IM in the thigh immediately after birth, followed by a complete course of three injections of recombinant hepatitis B vaccines approved for children to be started within the first ___ of life
0.5
12h
343
.For those experiencing a direct percutaneous inoculation or transmucosal exposure to HBsAg-positive blood or body fluids (e.g., accidental needle stick, other mucosal penetration, or ingestion), a single IM dose of HBIG, ___ mL/kg, administered as soon after exposure as possible, is followed by a complete course of hepatitis B vaccine to begin within the first week.
0.06
344
For persons exposed by sexual contact to a patient with acute hepatitis B, a single IM dose of HBIG, ____ mL/kg, should be given within ___days of exposure, to be followed by a complete course of hepatitis B vaccine
0.06
14
345
Specifically, for hemodialysis patients, annual anti-HBs testing is recommended after vaccination; booster doses are recommended when anti-HBs levels fall to <___ mIU/mL.
10
346
T/F
IG is ineffective in preventing hepatitis C and is no longer recommended for postexposure prophylaxis in cases of perinatal, needle stick, or sexual exposure
True
347
Two safe and effective three-dose (0, 1, and 6 months), recombinant genotype ___ capsid protein vaccines, which protect against other genotypes as well, have been shown in randomized, placebo-controlled trials to be highly protective against symptomatic acute hepatitis E
1
348
____, a validated algorithm based on such routine lab tests as (AST and ALT) levels and platelet counts (PLT) (age [years] × AST/PLT × ALT1/2); and imaging determinations of liver elasticity
FIB-4
349
The likelihood in a patient with HBeAg-reactive chronic hepatitis B of converting spontaneously from relatively replicative to nonreplicative infection is ~___% per year
10
350
most important risk factor for the ultimate development of cirrhosis and HCC in both HBeAg-reactive (beyond the early decades of “relatively nonreplicative” infection) and HBeAg-negative patients
level of HBV replication
351
1st line agents for chronic hep b infection
Of the eight approved treatments, PEG IFN, entecavir, and the two tenofovir preparations (TDF and TAF) are recommended as first-line agents, and generally, the oral agents are favored over injectable PEG IFN
352
Long-term monotherapy with lamivudine was associated with what mutation/s for hep b
Long-term monotherapy with lamivudine was associated with methionine-to-valine (M204V) or methionine-to-isoleucine (M204I) mutations, primarily at amino acid 204 in the tyrosine-methionine-aspartate-aspartate (YMDD) motif of the C domain of HBV DNA polymerase, analogous to mutations that occur in HIV-infected patients treated with this drug
353
Treatment for chronic hep c that may be given 1x a week
PEG IFN
354
In patients treated with PEG IFN, HBeAg and HBsAg responses have been associated with IL28B (now renamed IFN lambda-3, IFNL3) genotype __, the favorable genotype identified in trials of PEG IFN for chronic hepatitis C
CC
355
most potent of the HBV antivirals
Entecavir
just as well tolerated as lamivudine
356
What is the advantage of TAF vs TDF in chronic hepatitis
Tenofovir alafenamide (TAF) is a prodrug of tenofovir that requires activation to tenofovir in hepatocytes. This targeted delivery to hepatocytes allows a lower dose to suffice and reduces systemic exposure by 90%, thereby minimizing TDF-associated proximal tubular renal injury, its associated phosphate wasting, and the potential consequent loss of bone mineral density
The dose of TAF is 25 mg, which is equivalent in antiviral potency to 300 mg of TDF
357
TAF is recommended by AASLD and EASL over TDF in chronic hep patients with crea clearance < ___ ml/min, reduced bone density, and risk factors for renal injury
50
358
For HBeAg-positive patients with chronic hepatitis with ALT ≤2× the upper limit of normal, no antiviral tx is recommended unless
in patients >40, with family history of cirrhosis or hepatocellular carcinoma, with extrahepatic manifestations, with a history of previous treatment, and/or with liver biopsy (or noninvasive fibrosis determination) evidence for moderate to severe inflammation or fibrosis
359
When should you treat for chronic hep b?
360
When can you stop giving antivirals for HbeAg positive chronic hep b infected individuals?
Per current AASLD recommendations, antiviral treatment with oral agents can be stopped after HBeAg seroconversion in NONcirrhotics, and the suggested period of consolidation therapy is 12 months with close monitoring for recurrent viremia (monthly × 6, then every 3 months for the rest of a year) after cessation of therapy
361
When can you stop giving antivirals for HbeAg negative chronic hep b infected individuals?
For patients with HBeAg-negative chronic hepatitis, the current recommendation with oral agents is for indefinite therapy; stopping therapy in this group can be considered after HBsAg loss
so if negative na from the start, indefinite tx
362
For patients with compensated cirrhosis, because antiviral therapy has been shown to retard clinical progression, treatment is recommended regardless of HBeAg status and ALT as long as HBV DNA is detectable at >_____ (detectable at any level according to the EASL);
2 × 10^3 IU/mL
363
What are the advantages of nucleoside analogs over PEG IFN for tx of chronic hep B
taken orally
effective in high HBV level DNA > 10^9
may be used in cirrhosis, transplant px and immunosuppressed
less costly
364
why shuld you not use lamivudine as monotherapy in px with HBV-HIV infection ?
Lamivudine should never be used as monotherapy in patients with HBV-HIV infection because HIV resistance emerges rapidly to both viruses
365
A distinguishing serologic feature of chronic hepatitis D is the presence in the circulation of antibodies to ____
liver-kidney microsomes (anti-LKM)
however, the anti-LKM seen in hepatitis D, anti-LKM3, are directed against uridine diphosphate glucuronosyltransferase and are distinct from anti-LKM1 seen in patients with autoimmune hepatitis and in a subset of patients with chronic hepatitis C
mnemonic: 3D
366
the only approved drug for hepatitis D
standard IFN-α is the only approved drug for hepatitis D
367
best prognostic indicator in chronic hepatitis C
liver histology
most impt predictor of progression to chronic infection: duration of infection
367
Immune complex–mediated extrahepatic complications of chronic hepatitis C are less common than in chronic hepatitis B , with the exception of __________
essential mixed cryoglobulinemia
368
Patient variables that correlated with better response to IFN therapy for Chronic hep C
Patient variables that correlated with IFN-based SVRs included favorable genotype (genotypes 2 and 3 as opposed to genotypes 1 and 4; genotype 1b as opposed to genotype 1a); low baseline HCV RNA level (<800,000 IU/mL), low HCV quasispecies diversity, and histologically mild hepatitis and minimal fibrosis, especially absence of cirrhosis; immunocompetence; low liver iron levels; age <40; female gender; and absence of obesity, insulin resistance, type 2 diabetes mellitus, and hepatic steatosis.
369
most pronounced ribavirin side effect is ________
most pronounced ribavirin side effect is hemolysis, often requiring dose reduction or addition of erythropoietin therapy
370
What antiviral for chronic hep c has efficacy in all genotypes
Sofosbuvir has efficacy in all genotypes (1–6); in treatment-naïve subjects and prior nonresponders to PEG IFN–based and protease-inhibitor-based therapy; with PEG IFN–ribavirin or in IFN-free regimens; in combination with ribavirin or with NS5A inhibitors (see below); and for treatment periods as brief as 8–12 week
371
What are the standard indications for therapy of chronic HCV infection?
372
Cardiac problem assciated with sofosbuvir containing regimens
All sofosbuvir-containing regimens can be associated with severe bradycardia in patients taking the antiarrhythmic agent amiodarone, especially along with beta blockers; sofosbuvir-containing combinations are contraindicated with amiodarone
373
Prior to treating chronic HCV, what should be determined first?
Prior to therapy, HCV genotype should be determined, because the genotype contributes to decisions about which treatment regimens are indicated
374
Difference between Type 1 Autoimmune hepatitis vs Type 2
Type I autoimmune hepatitis is the classic syndrome prevalent in North America and northern Europe occurring in young women, associated with marked hyperglobulinemia, lupoid features, circulating ANAs, and HLA-DR3 or HLA-DR4 (especially B8-DRB1* 03). Also associated with type I autoimmune hepatitis are autoantibodies against actin and atypical perinuclear antineutrophilic cytoplasmic antibodies (pANCA).
Type II autoimmune hepatitis, often seen in children, more common in Mediterranean populations, and linked to HLA-DRB1 and HLADQB1 haplotypes, is associated not with ANA but with anti-LKM. . In type II autoimmune hepatitis, the antibody is anti-LKM1, directed against cytochrome P450 2D6.
375
mainstay of management in autoimmune hepatitis
glucocorticoid tx
Although some advocate the use of prednisolone, prednisone is just as effective and is favored by most authorities. Tx may be initiated at 20 mg/d, but a popular regimen in the US relies on an initiation dose of 60 mg/d. This high dose is tapered successively over of a month down to a maintenance level of 20 mg/d.
An alternative, but equally effective, more appealing approach is to begin with half the prednisone dose (30 mg/d) along with azathioprine (50 mg/d). With azathioprine maintained at 50 mg/d, the prednisone dose is tapered over the course of a month down to a maintenance level of 10 mg/d.
376
For Shigella, enterohemorrhagic Escherichia coli, Giardia lamblia, or Entamoeba, as few as ____ bacteria or cysts can produce infection, while ____ Vibrio cholerae organisms must be ingested to cause disease
10–100
10^5 −10^8
377
Pathogens that cause diarrhea via enterotoxin
378
Pathogens that cause diarrhea via cytotoxin
379
People with blood group ___ show increased susceptibility to disease due to V. cholerae, Shigella, E. coli O157, and norovirus
O
380
the most common travel-related infectious illness
traveler’s diarrhea
The time of onset is usually 3 days to 2 weeks after the traveler’s arrival in a resource-poor area; most cases begin within the first 3–5 days. The illness is generally self-limited, lasting 1–5 days. The high rate of diarrhea among travelers to underdeveloped areas is related to the ingestion of contaminated food or water
381
If the diarhea persisted for > __ days, stool must be tested for parasites
10
382
If stool sample reveled WBCs, you should culture for what organisms?
Culture for: Shigella, Salmonella, Campylobacter jejuni
Consider: Clostridioides difficile cytotoxin
383
Individuals with hypogammaglobulinemia are at particular risk of ______ which may cause diarrhea
C. difficile colitis and giardiasis
384
What causative organisms can cause food poisoning that has an incubation period of 1-6h
Staphylococcus aureus or B. cereus, has the shortest incubation period (1–6 h) and generally lasts <12 h
The emetic form of B. cereus food poisoning is associated with contaminated fried rice
385
What causative organisms can cause food poisoning + dysentery
386
What causative organisms can cause food poisoning + inflammatory diarrhea
387
How do you treat traveler's diarrhea
If the level of suspicion is low for fluoroquinolone-resistant Campylobacter
Adults:
(1) A fluoroquinolone such as ciprofloxacin, 750 mg as a single dose or 500 mg bid for 3 days; levofloxacin, 500 mg as a single dose or 500 mg qd for 3 days; or norfloxacin, 800 mg as a single dose or 400 mg bid for 3 days.
(2) Azithromycin, 1000 mg as a single dose or 500 mg qd for 3 days.
(3) Rifaximin, 200 mg tid or 400 mg bid for 3 days (not recommended for use in dysentery).
If fluoroquinolone-resistant Campylobacter is suspected (for example, following travel to Southeast Asia):
Adults: Azithromycin (at above dose for adults).
388
Characteristic pain from the abdominal wall
Pain arising from the abdominal wall is usually constant and aching
389
Most common non infectious cause of acute diarrhea
Medication induced
390
Example of cytotoxin producing microorganisms
EHEC, C. difficile
391
Example of preformed enterotoxin producing microorganisms
S. aureus, B. cereus, ETEC, V. cholerae
392
Recommended treatment for C. difficile colitis
Oral vancomycin
Metronidazole
Fidaxomicin
393
Type of diarrhea that ceases with fasting
osmotic diarrhea
2 most common causes: Magnesium and lactose
394
Colchicine causes this type of diarrhea
Steatorrhea
may also be caused by cholestyramine
395
Type of diarrhea that presents with positive calprotectin
Inflammatory
396
Significant weight loss
Loss of 4.5 kg or >5% of ones body weight over6-12 months
397
Differentiate forrest class types
398
Forrest Class types that would require intensive PPI tx
IA, IB , IIA, IIB
399
His ALP is elevated out of proportion to her ALT/AST. CT/MRCP/ERCP is most likely warranted if:
Ducts are dilated; with extrahepatic cholestasis
400
most common cause of extrahepatic cholestasis
Choledocholithiasis
The clinical presentation can range from mild rightupper-quadrant discomfort with only minimal elevations of enzyme test values to ascending cholangitis with jaundice, sepsis, and circulatory collapse
401
cornerstone of therapy for dumping syndrome
dietary modification
402
What variables are included in Meld Na
Crea, INR, bilirubin
402
Causes of inc ALP
>60 yrs old
>Blood type O and B after fatty meal (due to influx of intestinal ALP
>child and adolescent (bone ALP)
> late pregnancy (placental ALP)
403
single best acute measure of hepatic synthetic function and helpful in both diagnosis and assessing the prognosis of acute parenchymal liver disease
measurement of clotting factors due to rapid turnover
404
T/F Vitamin K will likely correct prolonged PT in cholestasis
True since vitamin K requires biliary excretion for its subsequent absorpton
405
Interpret
HBsAg (+); Anti HBs (+); Anti
HBc (+), HbeAg (+) Anti HBe (-)
HBsAg of one subtype and heterotypic anti-HBs
Heterotypic anti-HBs is a condition where a person has both hepatitis B surface antigen (HBsAg) and anti-HBs, but the subtypes of the two are differen
406
Interpret
HBsAg (+); Anti HBs (-); Anti
HBc IgG (+), HbeAg (+) Anti HBe (-)
Chronic hepatitis B, high infectivity
407
For pregnant mothers with high-level HBV DNA (>2 × 10^5 IU/mL), the addition of this drug during the third trimester of pregnancy reduces perinatal transmission even further
Tenofovir
Pregnancy category B
408
A distinguishing serologic feature of chronic hepatitis D is the presence in the circulation of:
Anti LKM 3
409
Interpretation of R factor >5
hepatocellular
410
FDA recommended daily dose of Paracetamol is
3g
411
How long should you hold the following before high risk endoscopy procedure
Aspirin
Clopidogrel
Ticagrelor
Prasugrel
Aspirin - no need to hold unless aspirin with dypiridamole (2-7 days)
Clopidogrel- 5 days
Ticagrelor- 5 days
Prasugrel- 7 days (P-pito)
412
Chronic alcoholism and pernicious anemia are associated with what type of gallbladder stone
Pigment
413
Serial monitoring of serum bun and hct in acute panc should be done every ____
8-12h
414
Population requiring surveillance with liver utz +/- AFP
> Cirrhotic regardless of etiology
> FMHx of HCC
> Asians > 40 with chronic hep b
> Africans > 20 with chronic hep b
> HCV related fibrosis (METAVIR F3)
415
Alarm symptoms for GERD
Odynophagia/dysphagia
Unexplained weight loss
Recurrent vomiting
Occult or gross GI bleeding
**Jaundice**
Palpable lymphadenopathy
Fmhx of gastroesophageal malignancy
416
Which type of ulcer (gastric vs duodenal) presents with pain precipitated by food intake
gastric
417
Which of the following surgical procedures leading to a short bowel has the highest risk of having severe diarrhea?
A. Resection of the ileocecal valve
B. Resection of the sigmoid colon
C. Resection of the transverse colon
D. Resection of the jejunum
A. Resection of the ileocecal valve
418
T/F
Immunocompromised patients with symptomatic hemorrhoids will benefit from rubber band ligation and hemorrhoidectomy
False
No procedures on hemorrhoids should be done in px who are immunocompromised or who have active proctitis
418
A 38-year-old man is admitted to the ICU post-operatively after sustaining multiple stab wounds. He remains hemodynamically stable, and over the next few days does not worsen clinically. Abdominal PE is unremarkable, and surgical site is dry. A decision to start bolus NGT feedings with a commercial formula is made. 1 day later, he reports watery diarrhea occurring 4x/day. Laboratory investigations do not show any signs of infection.What is the most appropriate management in this case?
A. Continue with tube feeding and start loperamide per orem
B. Continue with tube feeding but shift to elemental feeding
C. Discontinue tube feeding; place patient on NPO status until diarrhea resolves
D. Discontinue tube feeding; shift to parenteral nutrition
A. Continue with tube feeding and start loperamide per orem
419
Interpret
HbsAg NR
HbcAg NR
Anti Hbs NR
Anti Hbc IgM NR
Anti Hbc IgG reactive
HbeAg NR
anti Hbe NR
Low level hepatitis b carrier
420
Which among the following individuals with non-alcoholic steatohepatitis (NASH) has the highest risk for progressive hepatic fibrosis?
A. 45 year old male, with concomitant chronic hepatitis B infection
B. 50 year old female, obese, with uncontrolled diabetes mellitus
C. 55 year old male, with family history of cirrhosis from NASH
D. 60 year old female, on estrogen therapy
B. 50 year old female, obese, with uncontrolled diabetes mellitus
Highest in NASH > 45-50y/o with DM and Is overweight/obese
421
Aside from thrombocytopenia, which of his laboratory results is a marker for severe portal hypertension?
A. Prothrombin time
B. Serum sodium
C. Total bilirubin
D. WBC count
B. Serum sodium
422
Emphysematous cholecystitis occurs most frequently in these subset of px
Elderly men
DM px
423
A 73-year-old woman is admitted to the ER with fever, epigastric abdominal pain, and jaundice. She has had recurrent mild right upper quadrant (RUQ) pain over the last 6 months. She has no known history of liver or biliary disease. She is received hypotensive, febrile, and disoriented. Initial laboratories are as follows: Hgb 13 g/dL, WBC 19,000/uL, ALT 435 U/L, TB 8.3 mg/dL. Ultrasound of the RUQ reveals dilated intrahepatic and extrahepatic bile ducts, gallstones, a normal gallbladder wall, and no pericholecystic fluid. The pancreas is not well visualized.Which of the following is the best therapeutic strategy?
A. Broad spectrum IV antibiotics
B. ERCP with sphincterotomy
C. Open cholecystectomy with bile duct exploration
D. Percutaneous transhepatic biliary drainage
B. ERCP with sphincterotomy
Patient has acute cholangitis. ERCP with sphincterotomy is the procedure of choice for dx and txc
424
A 44-year-old man is admitted for severe epigastric pain of 2 days duration. Pertinent in his course is transient hypotension and an elevated creatinine level (2.1mg/dL) which resolved after aggressive fluid administration. What is the severity of the pancreatitis?
A. Mild acute pancreatitis
B. Moderate acute pancreatitis
C. Moderately severe acute pancreatitis
D. Severe acute pancreatitis
C. Moderately severe acute pancreatitis
with transient organ failure (<48h)
425
A 38-year-old who had an episode of acute pancreatitis 6 weeks prior comes in with recurrent epigastric pain. He is afebrile, and aside from the abdominal pain, has no other symptoms. An abdominal CT scan is done revealing a 6-cm well-circumscribed, homogenous fluid collection at the epigastric area, with no nonliquid components. What is the most appropriate treatment approach in this case?
A. Course of antibiotics
B. Endoscopic drainage
C. Mesenteric angiography and embolization
D. No active intervention is indicated; observe for now
B. Endoscopic drainage
Only symptomatic collections should be drained
426
Probiotics that may be given to prevent acute infectious diarrhea
Based on CPG (2019) gudidelines
Bifidobacterium lactis
Lactobacillus rhamnosus GG
Lactobacillus reuteri
427
marker/s that represent chronic replicative phase of HBV infection
Hbsag and HBV dna
428
Which of the following conditions can cause presinusoidal intrahepatic portal hypertension?
A. Schistosomiasis
B. Venoocclusive syndrome
C. Cirrhosis
D. Congenital hepatic fibrosis
A. Schistosomiasis
also D?
Venooccusive is post sinusoidal
429
What is the treatment of choice for first recurrence of Clostridium difficile infection?
A.Vancomycin
B.Metronidazole
C.Rifaximin
D.Fidaxomicin
D.Fidaxomicin
Decreases recurrence rates
430
esophageal lumen size is commonly associated with solid food dysphagia
< 13 mm
431
What is the characteristic radiologic computed tomography features of necrotizing pancreatitis?
A.Pancreatic parenchyma enhancement by IV contrast agent
B.Lack of pancreatic parenchyma enhancement by IV contrast agent
C.Heterogenous liquid and nonliquid density with varying degrees of loculations
D.Homogenous collection with fluid density
B.Lack of pancreatic parenchyma enhancement by IV contrast agent
432
A 19 year old female was brought to the E.R. due to loss of consciousness. She was thought to be sleeping when her parents checked on her at 6:00AM, but at 11:00AM was ultimately found to be unconscious. Beside her was an almost empty, newly opened bottle of Acetaminophen 600mg. Which of the following treatment principles about this case is CORRECT?
A. Activated charcoal is still effective even if given >30 minutes after Acetaminophen ingestion.
B. Adding sodium bicarbonate to N-Acetylcysteine within 24 hours of Acetaminophen have shown to reduce hepatic necrosis.
C. Treatment with N-Acetylcysteine will only be partially effective if given after 24-36 hours of Acetaminophen overdose.
D. Cholestyramine is as potent as N-Acetylcysteine when given with Activated charcoal in the next 24 to 48 hours after Acetaminophen overdose.
C. Treatment with N-Acetylcysteine will only be partially effective if given after 24-36 hours of Acetaminophen overdose.
433
A 48 year old male consulted due to 2 month history of on and off diarrhea with associated crampy abdominal pain, tenesmus and passage of mucus. Three days prior to this consult, patient noted blood on his stool. Pertinent P.E. findings showed tenderness in anal canal and there was blood on rectal examination. There was also tenderness on palpation of the abdomen. Which of the following is TRUE about the management of this disease?
A. Antibiotics are very effective in the treatment of active or quiescent phase of the disease.
B. Sulfasalazine may be effective in inducing remission of the disease but not on maintaining it
C. Hydrocortisone enema may control active disease and have a proven role in maintenance therapy.
D. Cyclosporine can be given in severe cases that is refractory to steroids and can even be an alternative to colectomy.
D. Cyclosporine can be given in severe cases that is refractory to steroids and can even be an alternative to colectomy.
434
A 38 year old female consulted due to 3 month history of intermittent episodes of crampy abdominal pain, occurring almost every day and it was associated with change in frequency and form of stools. Patient claimed that there were times she will experienced diarrhea and at times, constipation. Which of the following treatment options is TRUE regarding the management of this case?
A. Cholestyramine is more potent than Loperamide in controlling diarrhea.
B. Antidepressants may improve constipation but not diarrhea.
C. Anti-cholinergic drugs may be helpful in alleviating painful cramps related to intestinal spasms.
D. Probiotics may improve the stool consistency and may regularize stool frequency
C. Anti-cholinergic drugs may be helpful in alleviating painful cramps related to intestinal spasms.
435
A 45 year old female was rushed to E.R. due to severe epigastric pain radiating to the back with pain score of 8-9/10. Patient was in distressed. Two weeks ago, she was told by her physician that her triglycerides was 1250 mg/dL. She was prescribed with medication but she did not comply. The amylase and lipase were both elevated, 6 times than the normal values. Aside from this findings, which of the following laboratory results is consistent with her condition?
A. Hyperbilirubinemia
B. Hemodilution
C. Hypercalcemia
D. Hypoglycemia
A. Hyperbilirubinemia
B. Hemodilution- hemoconcentration
C. Hypercalcemia- hypocalcemia
D. Hypoglycemia- hyperglycemia since dec beta cells
436
Definition of clinically impt weight loss
Clinically important weight loss is defined as the loss of 10 pounds (4.5 kg) or >5% of one’s body weight over a period of 6–12 months.
lean body mass (fat-free mass) begins to decline at a rate of 0.3 kg per year in the third decade, and the rate of decline increases further beginning at age 60 in men and age 65 in women.
437
Lab tests needed for unintended weight loss
438
Grade of ascites detectable on PE
Grade 1 ascites is detectable only by ultrasonography; **grade 2** ascites is detectable by physical examination; and grade 3 ascites results in marked abdominal distention
439
Abdominal swelling + umbilical venous hum suggests
An umbilical venous hum may suggest the presence of portal hypertension, and a harsh bruit over the liver is heard rarely in patients with hepatocellular carcinoma or alcohol-associated hepatitis.
440
Most common site for paracentesis
Once the presence of ascites has been confirmed, the etiology of the ascites is best determined by paracentesis, a bedside procedure in which a needle or small catheter is passed transcutaneously to extract ascitic fluid from the peritoneum. The lower quadrants are the most frequent sites for paracentesis. The left lower quadrant is preferred because of the greater depth of ascites and the thinner abdominal wall.
Paracentesis is a safe procedure even in patients with coagulopathy; complications, including abdominal wall hematomas, hypotension, hepatorenal syndrome, and infection, are infrequent
441
Conditions that will present with SAAG > 1.1 mg/dL and ascitic protein <2.5
Liver cirrhosis
Late Budd Chiari
Massive Liver Mets
Note: early budd chiari has ascitic >2.5
An ascitic protein level of ≥2.5 g/dL indicates that the hepatic sinusoids are normal and are allowing passage of protein into the ascites, as occurs in cardiac ascites, early Budd-Chiari syndrome, or sinusoidal obstruction syndrome. An ascitic protein level <2.5 g/dL indicates that the hepatic sinusoids have been damaged and scarred and no longer allow passage of protein, as occurs with cirrhosis, late Budd-Chiari syndrome, or massive liver metastases.
442
Initial tx for cirrhotic ascites
The initial treatment for cirrhotic ascites is restriction of sodium intake to 2 g/d
When sodium restriction alone is inadequate to control ascites, oral diuretics—typically the combination of spironolactone and furosemide—are used to increase urinary sodium excretion
Furosemide is a loop diuretic that is generally combined with spironolactone in a ratio of 40:100; maximal daily doses of spironolactone and furosemide are 400 mg and 160 mg, respectively. Fluid intake may be restricted in patients with hyponatremia.
443
When should aspirin be resumed in px with GI bleeding who are on aspirin for established cardiovascular dse ?
Patients with established cardiovascular disease who develop bleeding ulcers while taking low-dose aspirin for secondary prevention should restart aspirin as soon as possible after their bleeding episode (1–7 days).
In contrast, aspirin probably should be discontinued in most patients taking aspirin for primary prevention of cardiovascular events who develop UGIB
Primary prevention : discontinued
Secondary prevention: ASAP
444
Tx for esophageal varices
Esophageal varices are treated with endoscopic ligation and an IV vasoactive medication (octreotide, somatostatin, vapreotide, terlipressin) for 2–5 days. Combination of endoscopic and medical therapy is superior to either therapy alone in decreasing rebleeding
445
Most common source of obscure bleeding
Patients without a source of GIB identified on upper endoscopy and colonoscopy were previously labeled as having obscure GIB. With the advent of improved diagnostic modalities, ~75% of GIB previously labeled obscure is now estimated to originate in the small intestine beyond the extent of a standard upper endoscopic exam.
Small-intestinal GIB may account for ~5% of GIB cases. The most common causes in adults include vascular ectasias, neoplasm (e.g., gastrointestinal stromal tumor, carcinoid, adenocarcinoma, lymphoma, metastases), and NSAID-induced erosions and ulcersa
445
Most common cause of LGIB
Hemorrhoids are probably the most common cause of lower GIB (LGIB); anal fissures also cause minor bleeding and pain. If these local anal processes, which rarely require hospitalization, are excluded, the most common cause of LGIB in adults is diverticulosis.
446
What constitutes Glasgow Blatchford score?
447
Initial test if massive bleeding is suspected to be from small intestine
In patients with massive bleeding suspected to be from the small intestine, current guidelines suggest **angiography as the initial test**, with CT angiography or 99mTc-labeled red cell scan prior to angiography if the patient’s clinical status permits. For others, repeat upper and lower endoscopy may be considered as the initial evaluation because second-look procedures identify a source in up to ~25% of upper endoscopies and colonoscopies; a push enteroscopy, usually performed with a pediatric colonoscope to inspect the entire duodenum and proximal jejunum, may be substituted for a repeat standard upper endoscopy. If second-look procedures are negative, evaluation of the entire small intestine is performed, usually with video capsule endoscopy.
448
What age should FOBT for colorectal CA screening in avarage risk individuals commence?
Fecal occult blood testing is recommended only for colorectal cancer screening, beginning at age 45–50 years in average-risk adults
449
The type of food causing dysphagia is an important consideration. Intermittent dysphagia that occurs only with solid food implies structural dysphagia, whereas constant dysphagia with both liquids and solids strongly suggests an esophageal motor abnormality. Two caveats to this pattern are that despite having a motor abnormality which include
Two caveats to this pattern are that despite having a motor abnormality, patients with scleroderma generally develop mild dysphagia for solids only and that patients with oropharyngeal dysphagia often have greater difficulty managing liquids than solids.
450
Procedure/s of choice for dysphagia
If **oral or pharyngeal dysphagia** is suspected, a **fluoroscopic swallow study**, usually done by a swallow therapist, is the procedure of choice. Otolaryngoscopic and neurologic evaluation also can be important, depending on the circumstances.
For suspected **esophageal** dysphagia, **upper endoscopy** is the single most useful test. Endoscopy allows better visualization of mucosal lesions than does barium radiography and also allows for procurement of mucosal biopsies
451
T/F Esophageal mucosal biopsies be obtained routinely in the evaluation of unexplained dysphagia
True
The emergence of eosinophilic esophagitis as a leading cause of dysphagia in both children and adults has led to the recommendation that esophageal mucosal biopsies be obtained routinely in the evaluation of unexplained dysphagia even if characteristic, endoscopically identified esophageal mucosal features are absent
Esophageal manometry is done if dysphagia is not adequately explained by endoscopy or to confirm the diagnosis of a suspected esophageal motor disorder. Barium radiography can provide useful adjunctive information in cases of subtle or complex esophageal strictures, prior esophageal surgery, esophageal diverticula, or paraesophageal herniation.
Eosinophilic esophagitis is an important and increasingly recognized cause of dysphagia that is amenable to treatment by elimination of dietary allergens, proton pump inhibition or swallowed, topically acting glucocorticoids in combination with esophageal dilation for persistent stricturesa
452
In hemolytic disorders, serum bilirubin rarely exceeds ____
In these conditions, the serum bilirubin level rarely exceeds 86 μmol/L (5 mg/dL).
Higher levels may occur when there is coexistent renal or hepatocellular dysfunction or in acute hemolysis, such as a sickle cell crisis.
453
T/F
Pleural effusion may occur in cirrhosis **without** ascites
True
Right pleural effusion even in the absence of clinically apparent ascites may be seen in advanced cirrhosis.
454
What trimester does cholestasis of pregnancy occur?
Cholestasis of pregnancy occurs in the second and third trimesters and resolves after delivery
455
What is Stauffer's syndrome?
The term Stauffer’s syndrome has been used for intrahepatic cholestasis specifically associated with renal cell cancer
456
What carcinoma has the highest surgical cure rate of all the tumors that present as painless jaundice?
Ampullary carcinoma has the highest surgical cure rate of all the tumors that present as painless jaundice.
457
What side effects should be discussed to px taking these drugs as anti emetics: Domperidone, erythromycin, tricyclic antidepressants, and 5-HT3 antagonists
Domperidone, erythromycin, tricyclic antidepressants, and 5-HT3 antagonists increase risk of cardiac arrhythmias and sudden cardiac death in px with prolonged QTc
458
Upper endoscopy is recommended as the initial test in patients with unexplained dyspepsia who are >___ years old to exclude malignancy
60
459
First line for functional dyspepsia
PPI
Acid suppressants also are effective for both the postprandial distress and epigastric pain subtypes of functional dyspepsia. A meta-analysis of 18 controlled trials calculated a risk ratio of 0.88, with a 95% confidence interval of 0.82–0.94, favoring PPI therapy over placebo in functional dyspepsia. H2 antagonists also improve symptoms in functional dyspepsia, but a guideline has advocated PPIs over H2 antagonists as first-line therapies for functional dyspepsia. In addition to acid suppression, PPIs may have the additional action of reducing duodenal eosinophil counts in dyspepsia
460
Definition of diarrhea
Diarrhea is loosely defined as passage of abnormally liquid or unformed stools at an increased frequency. For adults on a typical Western diet, stool weight >200 g/d can generally be considered diarrheal.
Diarrhea may be further defined as acute if <2 weeks, persistent if 2–4 weeks, and chronic if >4 weeks in duration.
461
Indications for evaluation of diarrhea
Most episodes of acute diarrhea are mild and self-limited and do not justify the cost and potential morbidity rate of diagnostic or pharmacologic interventions. Indications for evaluation include **profuse diarrhea with dehydration, grossly bloody stools, fever ≥38.5°C (≥101°F), duration >48 h without improvement, recent antibiotic use, new community outbreaks, associated severe abdominal pain in patients aged >50 years, and elderly (≥70 years) or immunocompromised patients.**
462
Why is loperamide avoided in febrile dysentery
In moderately severe nonfebrile and nonbloody diarrhea, antimotility and antisecretory agents such as loperamide can be useful adjuncts to control symptoms. **Such agents should be avoided with febrile dysentery, which may be prolonged by them**, and should be used with caution with drugs that increase levels due to cardiotoxicity. Bismuth subsalicylate may reduce symptoms of vomiting and diarrhea but should not be used to treat immunocompromised patients or those with renal impairment because of the risk of bismuth encephalopathy
463
Antibiotic coverage is indicated, whether or not a causative organism is discovered in which subset of px with febrile dysentery?
Antibiotic coverage is indicated, whether or not a causative organism is discovered, in patients who are immunocompromised, have mechanical heart valves or recent vascular grafts, or are elderly
464
Which subset of px will need antibiotic prophylaxis for diarrhea
Antibiotic prophylaxis is only indicated for certain patients traveling to high-risk countries in whom the likelihood or seriousness of acquired diarrhea would be especially high, including those with immunocompromise, IBD, hemochromatosis, or gastric achlorhydria.
Use of ciprofloxacin, azithromycin, or rifaximin may reduce bacterial diarrhea in such travelers by 90%, though rifaximin is not suitable for invasive disease but rather as treatment for uncomplicated traveler’s diarrhea
465
What ARB is associated with diarrhea
The oral angiotensin receptor blocker olmesartan is associated with diarrhea due to spruelike enteropathy.
466
Measuring IgA tissue transglutaminase antibodies may help detect what dse?
Celiac dse
467
Patients suspected of having IBS should be initially evaluated with _____________
Patients suspected of having IBS should be initially evaluated with flexible sigmoidoscopy with colorectal biopsies to exclude IBD, or particularly microscopic colitis, which is clinically indistinguishable from IBS with diarrhea or functional diarrhea;
468
Any patient who presents with chronic diarrhea and hematochezia should be evaluated with ________
Any patient who presents with chronic diarrhea and hematochezia should be evaluated with **stool microbiologic studies and colonoscopy**
469
Next diagnostic step when px has chronic diarrhea and steatorrhea
470
Melanosis coli, or pigmentation of the colon mucosa, indicates the use of _______
Melanosis coli, or pigmentation of the colon mucosa, indicates the use of anthraquinone laxatives such as cascara or senna; however, this is usually apparent from a careful history
471
useful overall test of evacuation
A useful overall test of evacuation is the **balloon expulsion test**. A balloon-tipped urinary catheter is placed and inflated with 50 mL of water.
Normally, a patient can expel it while seated on a toilet or in the left lateral decubitus position. In the lateral position, the weight needed to facilitate expulsion of the balloon is determined; normally, expulsion occurs with <200 g added or unaided within 1 minute
In summary, a balloon expulsion test is an important screening test for anorectal dysfunction
472
most common cause of outlet obstruction in px with chronic constipation
The most common cause of outlet obstruction is **failure of the puborectalis muscle to relax**; this is not identified by barium defecography but can be demonstrated by magnetic resonance defecography, which provides more information about the structure and function of the pelvic floor, distal colorectum, and anal sphincters
473
Treatment for pelvic floor dysfunction as cause of chronic constipation
In patients with pelvic floor dysfunction alone, **biofeedback training** has a 70–80% success rate, measured by the acquisition of comfortable stool habits.
Attempts to manage pelvic floor dysfunction with operations (internal anal sphincter or puborectalis muscle division) or injections with botulinum toxin have achieved only mediocre success and have been largely abandoned.
474
Px with Family hx of FAP and HPNCC should undergo screening colonoscopy at what age
FAP : **10-12** yrs
HNPCC: **20-25** yrs (x2 of FAP yung age)
colonoscopy for FAP and HNPCC + 1-2 biopsies every 1-2yrs
FMHx of colon CA / polyp: 40
average risk: 45
475
What is a positive 24h esophageal pH recording for GERD?
pH <4 for >5% a day
475
GU perforation may damage which organ
L hepatic lobe
DU --> pancreas
476
T/F Px with NSAID induced GU/DU may be tx with H2 receptor antagonist and PPI
False
If NSAID will be continued despite injury, PPI is the only drug that can heal GU/DU ulcer
If will be d/c then may use H2 receptor antagonist
477
Histology of chronic gastritis that is an important predisposing risk factor for gastric CA
**Intestinal metaplasia**
Conversion of gastric glands to small intestinal phenotype with small bowel mucosal glands with goblet cells
Must undergo surveillance endoscopy evey **3 yrs**
478
Features less likely to be IBS
Onset at old age
progressive course
persistent diarrhea after 48h fast since fasting improves IBS
presence of nocturnal diarrhea or steatorrhea
479
Diagnostic results less likely to be IBS
Anemia
inc ESR
+ stool wbc/rbc
Stool volume > **200-300mL**
480
Initial tx of choice for IBS-D
peripherally acting opiates
480
pathognomonic lesion of Chron's dse
non caseating granuloma
480
A 50-year-old man with a long-standing history of chronic gastritis presents with complaints of worsening epigastric pain and frequent nausea after meals. He has been using aspirin regularly for his heart disease. Upon examination, he has signs of anemia and an upper endoscopy reveals multiple gastric erosions. Which of the following mechanisms is most likely responsible for the exacerbation of his gastric symptoms?
A. Increased production of gastric acid due to the suppression of prostaglandin synthesis, leading to mucosal injury.
B. Direct cytotoxic effect on gastric epithelial cells, disrupting tight junctions and increasing permeability.
C. Inhibition of mucus and bicarbonate secretion due to reduced local blood flow and impaired angiogenesis.
D. Enhanced gastric motility induced by aspirin, resulting in increased gastric mucosal exposure to HCl acid
C. Inhibition of mucus and bicarbonate secretion due to reduced local blood flow and impaired angiogenesis.
Given the clinical vignette, the patient seems to have NSAID-induced PUD.
A - Interruption of prostaglandin synthesis can impair mucosal defense and repair, thus facilitating mucosal injury via a systemic mechanism (not due to increased production of gastric acid)
B - Also true?
D - Aspirin does not enhance gastric motility
481
A 50-year-old patient with a long-standing H. pylori infection presents with dyspepsia & is diagnosed with a duodenal ulcer. Despite eradication of H. pylori, the patient develops recurrent duodenal ulcers. Based on the pathophysiology of H. pylori infection, which of the following steps BEST explains the potential mechanism of recurrent duodenal ulceration in this patient?
A. H. pylori's cytotoxin-associated gene A (Cag A) directly induces high gastric acid secretion by increasing the proliferation of parietal cells.
B. H. pylori's vacuolating toxin A (Vac A) inhibits parietal cell acid production, resulting in increased gastric metaplasia in the duodenum, leading to ulcers.
C. H. pylori infection reduces somatostatin-producing D cells, leading to elevated gastric acid and duodenal mucosal injury.
D. The dupA gene in H. pylori increases the production of reactive nitrogen species, leading to apoptosis of duodenal epithelial cells and ulcer formation.
C. H. pylori infection reduces somatostatin-producing D cells, leading to elevated gastric acid and duodenal mucosal injury.
A - H. pylori may directly inhibit parietal cell H+,K+-ATPase activity through a Cag A–dependent mechanism, leading in part to the **low** acid production observed after acute infection.
B - Vac A targets human CD4 T cells, inhibiting their proliferation, and in addition can disrupt normal function of B cells, CD8 T cells, macrophages, and mast cells.
D - Certain specific bacterial factors such as the DU-promoting gene A (dupA) may be associated with the development of DUs.
482
A 58-year-old man presents to the ED with worsening nausea, early satiety, and abdominal pain following a partial gastrectomy for gastric cancer five years ago. An upper endoscopy reveals marked mucosal erythema in the gastric remnant, while biopsy indicates minimal inflammation and epithelial cell injury. Despite initial treatment with cholestyramine, the patient reports persistent symptoms. What is the most appropriate next step to consider in this patient's management?
A. Dietary modification, followed by Triple Contrast Whole Abdomina CT Scan
B. Initiate therapy with a proton pump inhibitor (PPI) then do endoscopy in three months
C. Start octreotide 50 μg TID subcutaneously, then do PET Scan
D. Schedule a nuclear scan with 99mTc-HIDA then consider Roux-en-Y gastrojejunostomy
D. Schedule a nuclear scan with 99mTc-HIDA then consider Roux-en-Y gastrojejunostomy
483
A 45-year-old male presents with severe peptic ulcer disease and elevated fasting gastrin levels (>1000 pg/mL). Imaging reveals a duodenal mass, and endoscopy confirms multiple gastric ulcers. The patientis started on high-dose PPIs but continues to experience refractory symptoms. The mass does not show signs of metastasis. the patient undergoes surgical resection of the duodenal mass, with pathologyconfirming gastrinoma. However, a follow-up after 6 months shows persistent hypergastrinemia and recurring symptoms despite continued high-dose PPI therapy. Which of the following is the most appropriate next step in the management of this patient?
A. Start systemic chemotherapy with temozolomide an
capecitabine
B. Do second surgical exploration with a more aggressive tumor resection
C. Add somatostatin analogues to the PPI therapy
D. Proceed with peptide receptor radionuclide therapy
(PRRT
C. Add somatostatin analogues to the PPI therapy
Not yet metastatic
484
Aside from being therapeutic, what are the other advantages of ERCP over MRCP?
ERCP is better for periampullary lesions and primary sclerosing cholangitis
485
Mild to moderate stage of liver fibrosis can only be detected by _________
liver biopsy
486
SIngle best measurement of hepatic synthetic function
Coagulation factors
487
What liver conditions are the ff increased?
IgG
IgA
IgM
IgG= Autoimmune hepatitis
IgA= A-lcoholic liver dse
IgM= priMary biliary cholangitis
Other notes
normally IgG levels are low in cirrhosis due to inc synthesis of abx due to failure of cirrhiotic liver to clear bacterial antigens
488
T/F low grade fever is more common in HAV and HEV than HBV and HCV
True
except when HBV is heralded by serum sickness like syndrome
489
False positive anti hepatitis ___ virus IgM is seen in the presece of rheumatoid factor IgM
A
490
T/F
HCV RNA is a reliable marker of dse severity of HCV infection
False
not a reliable marker of dse severity or prognosis BUT predicts relative responsiveness to antiviral tx
HCV RNA assay most sensitive test for HCV infection
491
Which of the following statements is TRUE regarding Type A gastritis?
A. Type A gastritis primarily affects the antrum and spares the fundus and body of the stomach.
B. Antibodies against parietal cells are found in over 90% of patients with Type A gastritis.
C. Hypergastrinemia in Type A gastritis is due to increased gastric acid production.
D. Patients with Type A gastritis often have circulating antibodies against intrinsic factor
D. Patients with Type A gastritis often have circulating antibodies against intrinsic factor
492
A 32-year-old previously healthy male presents at the outpatient clinic with a 10-day history of watery diarrhea with crampy abdominal pain, nausea and vomiting. He recently returned from a Russian tour. The BEST treatment is _________________.
A. Metronidazole
B. Loperamide
C. Ciprofloxacin
D. Pantoprazole
A. Metronidazole
The patient’s presentation of prolonged watery diarrhea following travel to Russia suggests Giardia lamblia infection, a common cause of traveler’s diarrhea in this region. Giardia is a protozoan parasite often transmitted through contaminated water or food
493
A 45-year-old woman presents to the emergency department with a 3-day history of severe diarrhea, abdominal cramps, and fever. She has been experiencing up to 10 watery stools per day, accompanied by a significant loss of appetite. The patient reports that her symptoms began after attending a family barbecue, where she thinks she ate undercooked chicken. She has no known drug allergies and is not taking any medications. Which infectious agent is most likely responsible for her condition?
A. Vibrio parahaemolyticus
B. Escherichia coli (O157)
C. Listeria monocytogenes
D. Campylobacter jejuni
D. Campylobacter jejuni
494
A 35-year-old male presents with a history of intermittent dysphagia and recent esophageal food impactions. He also reports occasional chest pain and heartburn. He has a history of asthma and eczema. Anupper endoscopy reveals multiple esophageal rings, longitudinal furrows, and white exudates. Biopsies show ≥15 eosinophils per high-power field. Which of the following is the most appropriate initial management strategy for this patient?
A. Empiric elimination diet
B. Systemic glucocorticoid therapy
C. Proton Pump Inhibitor (PPI) therapy
D. Esophageal dilation
C. Proton Pump Inhibitor (PPI) therapy
495
A 58-year-old man with a history of cirrhosis secondary to chronic hepatitis C presents to the emergency department with hematemesis and melena. On examination, he is hypotensive with a blood pressure of 88/60 mmHg and tachycardic with a heart rate of 115 bpm. He appears jaundiced, has ascites, and shows signs of confusion. Laboratory tests reveal: TB 4.5 Albumin 2.5 INR 2.1 Crea 1.4. Endoscopy shows large esophageal varices with active bleeding. He was given IV octreotide and underwent endoscopic band ligation. On the second hospital day, the patient continues to have intermittent bleeding episodes. What would be the most appropriate next step in management?
A. Start high-dose proton pump inhibitor therapy and monitor closely.
B. Continue with endoscopic band ligation and octreotide infusion for 5 days.
C. Perform a transjugular intrahepatic portosystemic shunt (TIPS).
D. Schedule repeat endoscopy and consider surgery if bleeding persists.
C. Perform a transjugular intrahepatic portosystemic shunt (TIPS).
495
An upper endoscopy reveals Dieulafoy’s lesion. Which of the following BEST describes this condition?
A. An ulcer seen in patients with large hiatal hernia
B. An aberrant vessel in the mucosa bleeds from a pinpoint mucosal defect
C. Characterized by large volumes of hematochezia without a clear source
D. A vascular ectasia that occurs exclusively in patients with hereditary hemorrhagic telangiectasia
B. An aberrant vessel in the mucosa bleeds from a pinpoint mucosal defect
A - Cameron ulcer
C - Dieluafoy’s lesion is a less common cause of UGIB
D - Osler-Weber-Rendu
496
A 65-year-old male with a history of chronic NSAID use presents to the emergency room with hematemesis. Upper GI endoscopy reveals a gastric ulcer with a visible vessel. What is the next most appropriate management for this patient?
A. Endoscopic therapy
B. Intensive PPI therapy
C. Once-daily PPI therapy
D. Partial Gastrectomy
A. Endoscopic therapy
497
AF, a 55-year-old male came to your clinic due to his ultrasound result of fatty liver. He has a BMI of 30 and is currently taking medications for hypertension and diabetes mellitus with good control. What is the BEST initial management for this patient?
A. Refer for bariatric surgery
B. Start antioxidants like vitamin E
C. Lifestyle modification
D. Add Pioglitazone
C. Lifestyle modification
Lifestyle changes and dietary modifications that result in weight loss and/or improve insulin sensitivity are the primary treatments for NAFLD.
498
A 42-year-old Female known Diabetic and Hypertensive, diagnosed with Hepatic Fibrosis with a weight of 120kg, with a BMI of 30. How much weight loss will be beneficial for this case?
A. 4kg
B. 5kg
C. 7kg
D. 9kg
D. 9kg
Many studies indicate that loss of 3–5% of body weight improves steatosis and that greater weight loss (i.e., ≥7–10%) improves steatohepatitis and hepatic fibrosis. Since this patient has a weight of 120kg, a 7% weight loss is 8.4kg. Hence a 9kg weight loss would be beneficial in this case.
499
A 23/M came in to your clinic due to jaundice and abdominal enlargement for 3 days. Upon your history, he's been drinking heavily since he was 18 years old. You requested for blood tests, which revealed elevated AST and ALT levels with normal bilirubin level and INR with Maddrey discriminant factor of 35. What is the BEST treatment plan?
A. Advise patient to stop taking alcohol
B. Refer for liver transplant
C. Start with prednisolone 40 mg/day
D. Do liver biopsy
C. Start with prednisolone 40 mg/day
500
41/M diagnosed with chronic hepatitis B came in to your clinic for 2nd opinion for his treatment. His blood tests revealed HBsAg positive, HBeAg positive, HBV DNA level of 22000 IU/mL and SGPT of 31. What is the BEST advise for the patient?
A. No treatment needed
B. Start patient with Tenofovir/Entecavir
C. Admit patient and start with PEG IFN
D. Request for whole abdomen ultrasound to check for fibrosis
A. No treatment needed
501
30/F came in to ER due to recurrent hematochezia and crampy abdominal pain. On PE, patient had stable VS, abdomen is soft with slight tenderness in all quadrants. Laboratory findings revealed elevated ESR, CRP with leukocytosis. Patient underwent colonoscopy with findings of symmetric and continuous mucosal inflammation from anorectal junction. What is the BEST initial management for this patient?
A. Oral 5-ASA
B. Oral Corticosteroids
C. IV corticosteroids
D. Infliximab
A. Oral 5-ASA
Given the clinical vignette, the patient seems to have ulcerative colitis. First line treatment is a 5-ASA agent. These agents are effective at inducing and maintaining remission in UC.
B and C - used in moderate to severe UC/CD D - a chimeric IgG1 antibody against TNF-α, which is approved for moderately to severely active inflammatory and fistulizing CD and UC
502
A 55/M presents to emergency room with severe right upper quadrant pain which radiates to back. He has had similar, but less severe, episodes over the past year. His past medical history is notable for obesity and dyslipidemia. On examination, he has stable vital signs and tender right upper quadrant. What is the most likely diagnosis?
A. Acute cholecystitis
B. Acute pancreatitis
C. Biliary colic
D. Acute Hepatitis
C. Biliary colic
Biliary colic begins quite suddenly and may persist with severe intensity for 30 min to 5 h, subsiding gradually or rapidly. It is steady rather than intermittent, as would be suggested by the word colic, which must be regarded as a misnomer, although it is in widespread use. An episode of biliary pain persisting beyond 5 hours should raise the suspicion of acute cholecystitis. Biliary colic is often associated with gallstones.
503
A 55/F came in to your clinic due to incidental finding of solitary radiopaque 6mm gallbladder stone. She is asymptomatic. What is the most appropriate management?
A. Refer to surgeon for prophylactic cholecystectomy
B. Start Ursodeoxycholic acid 10-15 mg/kg/day
C. Observe and Monitor
D. Open cholecystectomy due to its size
C. Observe and Monitor
In asymptomatic gallstone patients, the risk of developing symptoms or complications requiring surgery is quite small. Thus, a recommendation for cholecystectomy in a patient with gallstones should probably be based on assessment of three factors: (1) the presence of symptoms that are frequent enough or severe enough to interfere with the patient’s general routine; (2) the presence of a prior complication of gallstone disease, that is, history of acute cholecystitis, pancreatitis, gallstone fistula, etc.; or (3) the presence of an underlying condition predisposing the patient to increased risk of gallstone complications (e.g., a previous attack of acute cholecystitis regardless of current symptomatic status). Patients with very large gallstones (>3 cm in diameter) and patients harboring gallstones in a congenitally anomalous gallbladder might also be considered for prophylactic cholecystectomy. Since the patient did not have any of these factors, the most appropriate management is observation.
B - For good results within a reasonable time period, this therapy should be limited to radiolucent stones <5 mm in diameter.
504
42/M with Crohn’s disease presents with fever, abdominal pain and severe fatigue. Laboratory tests revealed elevated ESR, CRP and WBC. CT scan showed large abscess in right lower quadrant with thickened bowel wall. He has been on infliximab therapy for the past year. What is the most appropriate initial management for this patient?
A. Increase infliximab dose
B. Start broad spectrum oral antibiotics
C. Immediate laparotomy
D. Percutaneous drainage of abscess
D. Percutaneous drainage of abscess
Intraabdominal and pelvic abscesses occur in 10–30% of patients with CD at some time in the course of their illness. CT-guided percutaneous drainage of the abscess is standard therapy. Despite adequate drainage, most patients need resection of the offending bowel segment. Percutaneous drainage has an especially high failure rate in abdominal wall abscesses.
504
36/F with longstanding Crohn’s disease affecting colon presents for routine surveillance colonoscopy. During the procedure, multiple dysplastic polyps are found. Her last colonoscopy was 2 years ago and she had been compliant with her medication regimen. What is the most appropriate follow up recommendation based on these findings?
A. Do polypectomy and repeat colonoscopy after 6 months
B. Total colectomy
C. Change her current medication
D. Do surveillance colonoscopy annually
B. Total colectomy
505
A 68-year-old male presented with chronic abdominal pain, steatorrhea and weight loss. On further work-up, revealed diffuse calcifications with associated pancreatic ductal dilatation and stricture of the common bile duct on abdominal CT imaging, which are all consistent with chronic calcific pancreatitis. In patients with pancreatic ductal dilatation, what is the therapy of choice?
A. Ductal decompression with surgical therapy
B. Stent placement via ERCP (endoscopic retrograde cholangiogpancreaticography)
C. Celiac plexus block
D. Opioid medications
A. Ductal decompression with surgical therapy
506
Dissolution of gallstones using UDCA is found to be 50% effective only on very select stones. ALL of the following should be fulfilled except
A. Functioning gallbladder
B. radiolucent stones <5 mm in diameter
C. Cholesterol stones
D. Symptomatic stones
D. Symptomatic stones
507
A 56-year-old female, diagnosed case of Heart failure with chronic atrial fibrillation came in for OPD consult complaining of vague abdominal pain with no other associated symptoms. Upon physical examination, she had icteric sclerae and a palpable liver edge. She denies smoking, drinking alcohol and no illicit drug use. She had no prior surgeries nor hospitalization. Which among these medications may be associated hepatic steatosis?
A. Clopidogrel 75 mg tab
B. Atorvastatin 10 mg tab
C. Amiodarone 200 mg tab
D. Valsartan+Sacubitril 100 mg tab
C. Amiodarone 200 mg tab
508
A 49-year-old male, came to OPD for an annual executive check-up. He has an unremarkable past medical history with smoking history of 10 pack/year and chronic alcoholic beverage drinker. PE findings were unremarkable on all systems except with BMI of 35 kg/m2. Which among the following mechanisms is associated with NAFLD?
A. Triglyceride synthesis overwhelm triglyceride disposal
B. Triglyceride disposal overwhelm triglyceride synthesis
C. Fatty acid synthesis overwhelm Fatty acid disposal
D. Fatty acid disposal overwhelm Fatty acid synthesis
A. Triglyceride synthesis overwhelm triglyceride disposal
509
A 50-year-old, male, intravenous drug user presented with elevated liver enzymes and a reactive HBsAg result. Liver biopsy was done which showed bridging fibrosis with nodularity. At what stage of fibrosis does this patient currently have?
A. 1
B. 2
C. 3
D. 4
C. 3
bridging fibrosis + nodules = 3
510
Zieve’s syndrome is a triad of signs that can occur in patients with severe alcoholic hepatitis. Which of the following is not included in the triad?
A. Jaundice
B. Hemolytic anemia, characterized by presence of spurs and acanthocytes.
C. Hyperlipidemia
D. Elevated Bilirubin
D. Elevated Bilirubin
511
Jaundice is the hallmark symptom of liver disease. Which is also true in this physical examination finding?
A. Jaundice is already detectable at bilirubin level of <2.5mg/dL.
B. Jaundice without dark urine is typical of hemolytic anemia.
C. With severe cholestasis, the color of the stools will not be affected even in the presence of steatorrhea.
D. Patient usually report scleral icterus before they notice darkening of urine.
B. Jaundice without dark urine is typical of hemolytic anemia.
512
A 43/F came in due to RUQ pain, fever and anorexia. She brought in her previous abdominal ultrasound 6 months ago with results of fatty liver, nonvisualized pancreas and multiple gallstones. She mentioned that she has been experiencing mild upper abdominal pain in the past week but became more frequent and painful 3 days ago. You opted to repeat her ultrasound and blood work ups and considers initiating her on antibiotics. The organisms most frequently isolated by culture of gallbladder bile in these patients include the following except:
A. Escherichia coli
B. Klebsiella spp.
C. Entamoeba coli
D. Streptococcus spp
C. Entamoeba coli
Question has EXCEPT
513
A 48/F, with recent history of cholecystectomy, came in due to abdominal pain, colicky, non-radiating over the RUQ. Cholangiography revealed no demonstrable retained stones. What is the most likely diagnosis of this case?
A. Biliary strictures
B. Retained biliary calculi
C. Stenosis of SOD
D. Cystic duct stump syndrome
D. Cystic duct stump syndrome
514
What is the management of choice for Hinchey Stage 1b Diverticulitis?
A. Oral antibiotic therapy
B. IV antibiotic therapy
C. Percutaneous drainage with resection and anastomosis
D. Hartmann’s procedure
C. Percutaneous drainage with resection and anastomosis
515
Extending the right hip causes pain along posterolateral back and hip, suggesting retrocecal
appendicitis.
A. Obturator Sign
B. Rovsing’s Sign
C. Hamburger Sign
D. Iliopsoas Sign
D. Iliopsoas Sign
516
A 42-year-old male with Type 2 Diabetes Mellitus and BMI of 25, diagnosed with NAFLD 1 year ago came in for follow up consultation; His ALT is 170, AST 78, CBC with Platelet is normal, with FIB-4 index of 1.67 (indeterminate score). What would be next diagnostic step to confirm the severity of liver fibrosis?
A. Liver Biopsy
B. Transient elastography
C. Complete Liver Profile including Prothrombin Time
D. No further imaging test is necessary in this case
B. Transient elastography
517
A 62-year-old female with no previous therapy for the liver came for follow up for fatigue and occasional itchiness with her lab results: SGPT 74, SGOT 79, (+) HBsAg, (-) HBeAg, (+) anti-HBe, (-) anti-HBc and HBV DNA < 20 IU/mL. What does she have:
a. Acute hepatitis B, replicative phase
b. Acute hepatitis B, non-replicative phase
c. Chronic hepatitis B, replicative phase
d. Chronic hepatitis B, non-replicative phase
d. Chronic hepatitis B, non-replicative phase
517
Portal areas of the liver consist of small veins, arteries, bile ducts and lymphatics. Secreted bile flows:
a. From the hepatocytes to the sinusoids
b. From the portal areas to the sinusoids to the terminal hepatic areas
c. In a counter-current pattern
d. From zone 1 to zone 3
c. In a counter-current pattern
518
A 28-year-old male complained of 2-month history of hematochezia with frequent soft to watery stools of about 4 episodes per day, accompanied by weight loss and anorexia. Distal colon biopsy showed diffuse mucosal disease with no ulceration and no cobblestoning. Management for this condition:
a. Cyclophosphamide
b. Metronidazole
c. Rituximab
d. Sulfasalazine
d. Sulfasalazine
5-ASA initial tx
519
66-year-old diabetic male was admitted for debridement of cellulitis on the right foot. However on his 22nd hospital day, he developed watery stools occurring 4 episodes per day for the last 2 days, fever Tmax 38.9C, with CBC WBC 18,000, N88; The most sensitive and specific test for the isolation of this organism is:
a. Cell culture cytotoxin test on stool
b. Colonoscopy
c. Enzyme immunoassay for toxins A and B in stool
d. Nucleic acid amplification tests for toxins A and B in stool
d. Nucleic acid amplification tests for toxins A and B in stool
520
A 43-year-old female came for evaluation of gradual abdominal enlargement for the last 3 weeks, accompanied by bilateral leg swelling. On PE BP 160/100, CR 110, RR 22, T 36.8C. She has multiple cervical lymphadenopathy, neck veins not distended, decreased breath sounds bibasal; abdominal enlargement, with normoactive bowel sounds, negative hepatojugular reflux, non tender abdomen and grade 2 bipedal edema. Her SAAG was noted at <1.1g/dL. Possible differential would include:
a. Budd-Chiari syndrome
b. Congestive heart failure
c. Nephrotic syndrome
d. Sinusoidal obstruction syndrome
c. Nephrotic syndrome
Low SAAG (< 1.1 g/dL): Indicates ascites due to conditions where there is no significant portal hypertension.
Common causes include:
Nephrotic syndrome
Peritoneal carcinomatosis
Tuberculous peritonitis
Pancreatic ascites
521
A 39-year-old male with no known co-morbidities sought consult for a 3-year history of recurrent epigastric pains with nausea and vomiting. He took PPI for 1 month, but symptoms persisted. He underwent gastroscopy with biopsy which showed: inflammatory infiltrate extending deeper into the mucosa with progressive distortion and destruction of the glands. Based on these findings, what phase of chronic gastritis does he belong to?
a. Atrophic gastritis
b. Gastric atrophy
c. Gastric metaplasia
d. Superficial gastritis
a. Atrophic gastritis
522
A 65-year-old male admitted for syncope due to cardiomyopathy-associated ventricular tachycardia and had been on amiodarone drip for 3 days then oral amiodarone for 10 days developed jaundice and vomiting and later encephalopathy just when discharge was being planned. Which therapy provides a higher transplant-free survival?
a. Glucocorticoids
b. N-Acetylcysteine
c. Silymarin
d. Ursodeoxcholic acid
b. N-Acetylcysteine
This patient’s presentation suggests acute liver injury (ALI) secondary to amiodarone-induced hepatotoxicity, which is a rare but potentially severe complication. The therapy that provides higher transplant-free survival in cases of acute liver failure (ALF) or severe ALI is N-Acetylcysteine (NAC).
523
. Congestive splenomegaly with hypersplenism is common in patients with portal hypertension and is usually the first indication of portal hypertension in liver cirrhosis. They are characterized with the development of
a. Thrombocytosis and leukocytosis
b. Thrombocytosis and leukopenia
c. Thrombocytopenia and leukocytosis
d. Thrombocytopenia and leukopenia
d. Thrombocytopenia and leukopenia
In portal hypertension, congestive splenomegaly leads to hypersplenism, a condition where the spleen becomes overactive in filtering blood cells. This process causes the destruction or sequestration of blood cells, leading to:
Thrombocytopenia
Platelets are sequestered and destroyed in the enlarged spleen, making thrombocytopenia the earliest and most common finding.
Leukopenia
Hypersplenism also reduces circulating white blood cells by increased sequestration
524
A 52-year-old male diagnosed was diagnosed with gastric ulcer. What is true of its pathology:
a. Intake of Paracetamol increases the risk
b. NSAIDs induce increase in prostaglandin secretion
c. The organism associated is a gram-positive microaerophilic rod
d. The organism associated is S-shaped with multiple sheathed flagella
d. The organism associated is S-shaped with multiple sheathed flagella
525
A 38-year old female who was previously well, developed a 3 month history of progressive body weakness, body malaise, and fatigue. She has no history of illicit drug use, an occasional alcoholic drinker and a non-smoker. She is married with only one sexual partner, her husband who admits to having multiple partners in the last 3 years, prior to his marriage. The last 2 weeks patient has anorexia, nausea and occasional vomiting. Upon PE she has right upper quadrant tenderness. Her lab results showed: CBC: 12/0.39/WBC 14/N50, L45, M3, E2/plt 250; RBC 88, Creatinine 1.0, BUN 14, ALT 235, AST 100, TB 2.0 mg/dl, IgM anti HAV – Negative; IgM Anti-HBc-Positive; antiHbs – Negative; HBsAg – Positive; HBeAg-Negative; anti HCV Negative; HBV DNA >2 x104 IU/mL How will you manage this patient?
a. Anti-viral therapy is not recommended, suggest liver biopsy
b. Close monitoring of viral load every 3 months
c. Interferon therapy 5M units subcutaneously daily
d. Tenofovir 300mg OD PO
d. Tenofovir 300mg OD PO
526
A 62-year-old female came in due to epigastric pain radiating to the back. PMH: s/p cholecystectomy a year ago. Ultrasound showed absent gall bladder with dilated common bile duct. The present of choledocholithiasis should be suspected if
a. Elevation of aminotransferases 2-10 fold
b. Intrahepatic biliary dilatation
c. Presence of pruritus and acholic stools
d. Serum bilirubin levels > 20mg/dL
a. Elevation of aminotransferases 2-10 fold
Intrahepatic Biliary Dilatation (B): This may be seen in prolonged obstruction of the common bile duct or higher up in the biliary tree. While it suggests obstruction, it is not specific to choledocholithiasis alone and requires correlation with clinical and laboratory findings.
Presence of Pruritus and Acholic Stools (C): These are symptoms of cholestasis, which can occur in various biliary obstructions (e.g., malignancy, stricture). They are suggestive but not diagnostic of choledocholithiasis.
Serum Bilirubin Levels > 20 mg/dL (D): While serum bilirubin can rise due to obstruction, levels exceeding 20 mg/dL are more commonly seen in severe cholangitis, advanced malignancy, or hemolysis rather than isolated choledocholithiasis.
527
A 53-year-old female with T2DM came in with epigastric fullness and eructation. Ultrasound showed a 7mm gallstone. The best management advice would be:
a. Choleresis to increase biliary secretion
b. Expectant management
c. Gallstone dissolution with UDCA at 10-15 mg/kg/day. d. Prophylactic cholecystectomy
b. Expectant management
This patient has a gallstone detected on ultrasound but no symptoms directly attributable to gallstones, such as biliary colic, acute cholecystitis, or complications like choledocholithiasis or pancreatitis. In patients with asymptomatic gallstones, the standard recommendation is expectant management rather than immediate intervention.
528
A 39 year old male with history of 2 CVD infarcts when he was 19 years old and later when he was 25 years old, is admitted for severe generalized abdominal pains since 2 days now. He has no nausea/vomiting but with last bowel movement 4 days ago. On PE he has hypoactive bowel sounds, tender on light percussion on all quadrants, no ascites, no organomegaly, tender on all quadrants. DRE was negative. Abdominal X-ray showed “thumbprinting” on the bowel wall. The next diagnostic step for this condition:
a. Angiography with venous phase
b. Colonoscopy
c. Duplex scan
d. Ultrasound of the whole abdomen
a. Angiography with venous phase
This patient has a history of cerebrovascular infarcts at a young age and is now presenting with severe abdominal pain, hypoactive bowel sounds, and thumbprinting on abdominal X-ray. These findings are highly suggestive of mesenteric ischemia, likely due to a thrombotic or embolic event affecting the mesenteric vessels
529
A 38-year-old female comes in for recurrent bloody diarrhea. Fecalysis showed WBCs and RBCs, fecal lactoferrin is elevated. ESR and CRP are elevated. Ultrasound of the whole abdomen was unremarkable. The colonoscopy shows diffuse continuous inflammation of the bowel across the rectosigmoid. What key diagnostic test can confirm her likely condition?
a. CT scan of the whole abdomen with triphasic contrast
b. Endoscopic ultrasound of the rectum
c. Immune markers such as ANA and AMA
d. There is no key / definitive test for her condition.
d. There is no key / definitive test for her condition.
The patient presents with recurrent bloody diarrhea, fecal markers of inflammation (elevated lactoferrin), and systemic inflammation (elevated ESR and CRP). Colonoscopy findings of diffuse continuous inflammation across the rectosigmoid strongly suggest ulcerative colitis (UC).
UC is diagnosed based on a combination of clinical history, endoscopic findings, and histopathological evaluation of colonic biopsies.
530
A 44-year-old male, smoker, alcoholic was rushed to the ER for progressive, severe abdominal pain for the last 8 days. Initially described as burning, epigastric pain radiating to the back. On PE BP 60/40, CR 130s, RR 24, T 38.7C, dry mucosa, decreased breath sounds bibasal, faint blue discoloration on the periumbilicus, hypoactive bowel sounds, tender on all quadrants. The patient is currently in which phase of this condition?
a. First phase
b. Second phase
c. Third phase
d. Fourth phase
c. Third phase
The initial phase is characterized by intrapancreatic digestive enzyme activation and acinar cell injury.
The second phase of pancreatitis involves the activation, chemoattraction, and sequestration of leukocytes and macrophages in the pancreas, resulting in an enhanced intrapancreatic inflammatory reaction.
The third phase of pancreatitis is due to the effects of activated proteolytic enzymes and cytokines, released by the inflamed pancreas, on distant organs. The systemic inflammatory response syndrome (SIRS) and acute respiratory distress syndrome (ARDS), as well as multiorgan failure, may occur as a result of this cascade of local and distant effects.
531
A 43-year-old female came in from India with 2-week fever, abdominal pains, anorexia, weight loss and nausea and vomiting. She remembers having salmon colored rash that lasted for 3 days during the first week of fever. On PE BP 130/90, CR 80s, T39C. She has tender abdomen and hepatosplenomegaly. If she will be left untreated and develop chronic carriage, this will increase the risk for:
a. Coma vigil
b. Gallbladder cancer
c. Hemophagocytic syndrome
d. Osteomyelitis
b. Gallbladder cancer
Chronic carriers are at increased risk for chronic inflammation of the gallbladder, which may lead to metaplasia, dysplasia, and subsequent gallbladder cancer.
532
A 65 year old male came to the ER for increasing severity of epigastric pain. He has history of recurrent joint pains secondary to osteoarthritis that is relieved with intermittent intake of naproxen. Which of the following explains the pathophysiology of his condition?
a. Naproxen decreases HCL secretion of parietal cells
b. Naproxen decreases surface active phospholipid secretion
c. Osteoarthritis induces loss of gastroprotective prostaglandins
d. Pain of osteoarthritis commonly causes stress-induced ulceration.
b. Naproxen decreases surface active phospholipid secretion
533
A 24 year-old-male at the Intensive Care Unit was referred to you due to melena which eventually progressed to hematochezia. The patient suffers from traumatic brain injury secondary to a motor accident 12 days ago and is currently intubated. Which of the following is consistent with the case?
a. This type of gastric mucosal injury occurs only after at least 1 week of an acute injury or insult
b. An EGD will likely show bleeding mucosal ulcerations along the fundus and body of the stomach
c. He may have gastric ulceration that developed from several IV and oral medications he is receiving
d. H. pylori eradication therapy is a necessary component of his therap
b. An EGD will likely show bleeding mucosal ulcerations along the fundus and body of the stomach
SRMD typically involves the fundus and body of the stomach, where acid production is highest.
534
A 28 year old female medical student who is about to take her board exam came in to your clinic due to episodic and crampy lower abdominal pain relieved with defecation. She mentions having recurrent constipation alternating with non-bloody diarrhea. She denies anorexia, weight loss and family history of malignancies. She has experienced these symptoms at least once a week for the past 3 months. What will you do next?
a. Refer patient for EGD
b. Request for CBC and fecalysis
c. Refer patient for colonoscopy
d. Perform a hydrogen breath test
The patient's symptoms are consistent with irritable bowel syndrome (IBS). However, before confirming this diagnosis, it is crucial to exclude other conditions that can mimic IBS, particularly infections, inflammation, or malabsorption.
535
A 33-year old, female consulted because of 1-year history of recurrent colicky right lower quadrant pain that is followed by and relieved with soft to watery mucoid diarrhea. She also has intermittent low grade fever, and has lost 5 kilograms over the past 6 months. She is a smoker, nulligravid, and takes oral contraceptive pills. She has no family history of tuberculosis and cancer. She currently weighs 53 kg. Other pertinent PE showed a flabby abdomen, soft, with no mass or tenderness. She had normal chest finndings. There was no mass or tenderness on DRE, with yellowish stool on examining finger. Based on the above findings, what is the most likely diagnosis?
a. Tuberculous colitis
b. Ulcerative colitis
c. Crohn’s disease
d. CMV colitis
c. Crohn’s disease
Recurrent Right Lower Quadrant (RLQ) Pain: This is common in Crohn’s disease, particularly when the terminal ileum is involved
Chronic diarrhea is a hallmark of IBD, with Crohn’s disease often involving non-bloody or mucous-containing stools, unlike ulcerative colitis.
536
A 60-year old man is seen at the ER for watery stool occurring 3 times a day for the past 3 days. He had fever for a day which resolved with paracetamol. PE findings are as follows: BP (supine) = 140/90 mmHg, BP (seated) = 120/80 mmHg, HR (supine) = 110, HR (seated) = 115, RR = 22 breaths/min, Temp = 37.5C, hyperactive bowel sounds, tenderness at the umbilical area and left lower quadrant. Initial fecalysis showed watery, brown stool, 0-2 rbc, 8-10 wbc, no parasites or ova seen. What should you do next?
a. Start IV hydration with lactated Ringer’s solution
b. Start IV anti-emetic and low osmolarity oral rehydration solution
c. Start bismuth subsalicylate
d. Start Ciprofloxacin IV
a. Start IV hydration with lactated Ringer’s solution
With orthostatic hypotension
537
A 36-year old man working at a BPO company consults you for an elevated ALT. His ALT has been noted to be elevated on annual employment check-up for the last two years. He is otherwise asymptomatic. He does not drink alcoholic beverages or use recreational drugs. He has no history of viral hepatitis, and his previous hepatitis prodle did not reveal any infection. He is obese, with a BMI of 35 kg/m2. What can explain his condition?
a. Accumulation of cholesterol within the hepatocytes
b. Decreased adipokines
c. Hypoglycemia
d. Hyperinsulinemia
d. Hyperinsulinemia
This patient most likely has nonalcoholic fatty liver disease (NAFLD), a common condition associated with obesity, insulin resistance, and metabolic syndrome
Obesity and insulin resistance lead to hyperinsulinemia, which promotes: Increased de novo lipogenesis (fat synthesis in the liver). Reduced fatty acid oxidation in hepatocytes. Accumulation of triglycerides within hepatocytes, causing steatosis (fatty liver)
NAFLD = inc TAG not in liver not cholesterol
538
A 21-year-old previously healthy female was brought to the ER due to 1 month history of worsening jaundice associated with fatigue, mild abdominal pain, and intermittent nausea. Pertinent PE showed jaundice, tenderness in the RUQ and obliterated Traube’s space. Diagnostic exams revealed elevated transaminases (ALT 2103 IU/L, AST 2739 IU/L), hyperbilirubinemia, negative hepatitis panel and CT scan result of mild hepatic inkammation with mild splenomegaly. ANA was strongly positive. Liver biopsy which revealed panlobular necrosis What is the mechanism of the patient’s progressive liver injury?
a. Abnormalities of immunoregulatory control over cytotoxic lymphocytes
b. Cell-mediated immunologic attack directed against hepatocytes
c. Immune-complex deposition in hepatocytes
d. Humoral-mediated immunologic attack directed against hepatocytes
b. Cell-mediated immunologic attack directed against hepatocytes
Dx: autoimmune hepatitis
Initial tx would be high dose prednisone
539
Which of the following factors predisposes a patient to develop cholesterol stones?
a. Pregnancy
b. Cystic fibrosis
c. Chronic hemolysis
d. Alcoholic liver cirrhosis
a. Pregnancy
540
Which of the following mechanisms contribute to the formation of ascites in the presence of cirrhosis?
a. Activation of hepatic stellate cells which contributes to fibrogenesis and impeded blood flow
b. Decrease in systemic circulating levels of nitric oxide and vascular endothelial growth factor
c. Increase in RAAS activation which contributes to renal sodium and water excretion
d. Vasoconstriction of the splanchnic circulation and decrease in effective circulating volume
a. Activation of hepatic stellate cells which contributes to fibrogenesis and impeded blood flow
541
Which is the most important cause of upper GI erosions?
a. Acid
b. Alcohol intake
c. H. pylori
d. NSAID use
d. NSAID use
542
42/F comes to you with pain over her entire abdomen. On probing, she cannot localize the pain. She just came back today from a beach and mountain climbing trip in Palawan. Physical exam was unremarkable. Which of the following can you readily rule out without using additional tests?
a. Cholecystitis
b. Irritable bowel syndrome
c. Malaria
d. Mesenteric ischemia
a. Cholecystitis
543
5/M came for bloody diarrhea of 3 days duration. He also notes that he feels discomfort when urinating, ankle pain, and blurring of vision which he associates with tiredness. What is the most likely etiology?
a. Entamoeba dispar
b. Entamoeba histolytica
c. Enteroinvasive E. coli
d. Salmonella spp.
d. Salmonella spp.
This 35-year-old male presents with bloody diarrhea, urinary discomfort, ankle pain, and blurring of vision. These symptoms are consistent with reactive arthritis (formerly Reiter’s syndrome), which is a known complication of Salmonella spp. infections and other enteric pathogens.
544
What is true about diverticula?
a. A pseudodiverticula is a saclike herniation of the entire bowel wall through the muscularis propria
b. A true diverticula involves only a protrusion of mucosa and submucosa through the muscularis propria
c. Colonic diverticula commonly affect the left and sigmoid colon, as well as the rectum
d. The type of diverticulum most commonly affecting the colon is the pseudodiverticulum
d. The type of diverticulum most commonly affecting the colon is the pseudodiverticulum
545
What is correct about the pathophysiology of irritable bowel syndrome (IBS)?
a. A gastrointestinal infection may increase the likelihood of a patient developing IBS.
b. A highly blunted sensory response to visceral stimulation is seen in patients with IBS
c. No association between past sexual or physical abuse and development of IBS has been found.
d. There is increased diversity of microbiota in the intestinal flora of patients with IBS
a. A gastrointestinal infection may increase the likelihood of a patient developing IBS.
546
Most common cause of fulminant hepatitis
HBV
547
Only curative tx for fulminant hepatitis
Liver transplant
548
What abx is associated with vanishing bile duct syndrome
Co-Amox
549
Most impt risk factor for ultimate devt of cirrhosis and HCC in chronic HBV infection
Level of HBV DNA
if HCV: histology
550
How should a decompensated liver cirrhosis with chronic hep b with undetectable HBV DNA be managed?
Observe and refer for liver transplant regadless of HbeAg status and regardless of ALT level
since no use na antivirals since undetectable
no point in correcting transaminases since decompensated liver
551
When should a px with chronic hepatitis with chronic HBV be managed antivirals
If elevated >2 x 10^4 and >2x elevated ULN ALT, treat with antivirals
552
Patients with chronic HBV infection and with decompensated liver cirrhosis should not be treated with?
PEG IFN
Use oral agents only
553
How should a px with compesated cirrhosis wit HBV DNA > 2x 10^3 be managed
Treat with oral agents regardless of HbeAg and ALT status
554
One size fits all pangenotypic regimens for chronic HCV infection
Sofosbuvir-velpatasvir
Glecaprevir-pibrentasvir
555
How much weight loss is recommended for NAFLD
>= 3-5% improves serum AST/ALT and hepatic steatosis
>= 7-10% necessary for steatohepatitis and hepatic fibrosis
556
Best sensitivity and specificity for chronic panc
hormone stimulation test using secretin
initial modality of choice: WAB CT
557
Effect of TAG on amylase
hypergTAG causes spuriously normal amylase
558
When should cholecystectomy be done after discharge if with uncomplicated gallstone panc?
within same admission or 4-6 weeks after discharge
559
Which of the following is true regarding the diagnosis of ascites associated with cirrhosis?
a. Cirrhotic ascites usually present with SAAG <1.1 g/dL.
b. Ascitic protein level >2.5 g/dL indicates that the hepatic sinusoids have been damaged and scarred and no longer allow passage of protein, consistent with cirrhosis.
c. Diagnosis of SBP in cirrhotic ascites is defined as a white blood cell count of ≥250/ μL in the ascitic fluid.
d. The presence of multiple pathogens without an elevated PMN count suggests bowel perforation from the paracentesis needle.
d. The presence of multiple pathogens without an elevated PMN count suggests bowel perforation from the paracentesis needle.
a. Cirrhotic ascites usually present with SAAG <1.1 g/dL. - should be >
b. Ascitic protein level >2.5 g/dL indicates that the hepatic sinusoids have been damaged and scarred and no longer allow passage of protein, consistent with cirrhosis. less than not greater than
c. Diagnosis of SBP in cirrhotic ascites is defined as a white blood cell count of ≥250/ μL in the ascitic fluid.- PMN not WBC
560
Based on CPG guidelines how do you determine severity of dehydration due to diarrhea
561
Risk factors for diverticular bleeding
Hypertensive, atherosclerotic
On antithrombotic/ NSAIDs
Obese/ DM
