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Flashcards in Gastroenterology Deck (256):
1

Colonoscopy screening for ulcerative colitis

Every one to two years beginning 10 years after diagnosis for patients with disease extending beyond rectum

2

Irritable bowel syndrome workup with history of autoimmune disease

Check TTG rule out celiac disease - especially with type one diabetes and autoimmune thyroid disease

3

Acute fatty liver of pregnancy

Liver failure and coagulopathy

4

HELLP HEMOLYSIS, elevated liver enzymes, low plateletS

Microangiopathic hemolytic anemia

5

Resolved acute diverticulitis next step

After appropriate antibiotic therapy will require full colonoscopy to rule out other causes mimicking diverticulitis

6

Chest pain intermittent unrelated to exertion no reflux symptoms retrosternal pain seconds to minutes corkscrew on x-ray dysphasia to both liquids and solids

Diffuse esophageal spasm treat with calcium channel blockers/ppi - multiple simultaneous contractions on manometry

7

Many month history of dyspepsia looking like Gerd no alarm symptoms no physical exam abnormality what is treatment

Proton pump inhibitor

8

Hematochezia hypotension syncopal symptoms use of NSAIDs anemia what is next test to perform

Suspect upper G.I. source of bleeding needs upper endoscopy first - absence of blood or coffee ground material in NG tube does not rule out upper G.I. bleed - if negative then do colonoscopy

9

Treatment of new onset severely active Crohn's disease

Antitumor necrosis factor therapy like infliximab is best and better than immunomodulators such as mesalamine because Crohn's disease is transmural

10

Treatment of severe alcoholic hepatitis

Mandry discriminant function score of greater than 32 benefit from pentoxifylline if corticosteroids are contraindicated - like with kidney failure G.I. bleed active infections

11

How long to keep patient in hospital after high-risk peptic ulcer and a scopic treatment

72 hours - takes this long for high-risk peptic ulcer to become peptic ulcer

12

Patient with G.I. bleed due to angioectasias and aortic stenosis

replace aortic valve - heyde syndrome e - mechanical destruction of von Willebrand multimers during non-laminar flow through narrow aortic valve

13

Young patient history of several food impaction's history of allergies and asthma egd with concentric rings

Eosinophilic esophagitis treat with PPI or budesonide

14

Food regurgitation barium swallow dilated esophagus tapering gastroesophageal junction manometry decreased peristalsis increased lower esophageal pressure

Achalasia then do a EGD to rule out lymphoma cancer then a surgical myotomy

15

Regurgitating food eaten several days ago with halitosis

Zenkers diverticulum pouch in hypopharynx

16

odynophasia for more than 10 days

Egd to rule out esophagitis consider pill induced, radiation, infections like Candida CMV herpes

17

HIV patient with oral thrush complaining of odynophasia

No need for EGD right away treat empirically then if no improvement EGD to rule out CMV and herpes

18

Progressive dysphasia two solids heartburn several years

Peptic stricture

19

Patient with CVA hemiparesis with coughing and choking sensation was regurgitation of fluids to knows best diagnostic test

Video fluoroscopic swallowing study or modified barium swallow

20

Heartburn not remove by antacid initial diagnostic step is

Ppi challenge - step down to H2 if better in 3 months

21

If patient doesn't get better with PPI

EGD - if no esophagitis then ambulatory pH monitoring if little reflux than likely psychiatric give citalopram

22

Heartburn not respond – since with weight loss

Directly to EGD

23

Treatment of GERD with PPI's or fundoplication surgery effect on existing Barrett's

No effect

24

Barrett's esophagus EGD guidelines

After diagnosis the EGD one year later
NO Dysplasia ON REPEAT EGD NEXT ONE THREE-YEARs
Low-grade dysplasia repeat Egdsix months if still low-grade repeat yearly
If changes back to metaplasia continually EGD every three years
HIGH-GRADE DYSPLASIA ENDOSCOPIC HIGH FREQUENCY ABLATION

25

Severe retrosternal chest pain worse with swallowing and breathing - chest x-ray with left plural effusion subcutaneous emphysema

Esophageal rupture diagnosed with Gastrografin study

26

Best H. pylori test if taking PPI

Antibody ie serology test - only for diagnosis

27

Best H pylori test if not taking PPI

Fecal antigen test used for diagnosis and follow up

28

Urease breath test for H. pylori

Diagnosis and follow up

29

H pylori treatment failure with triple therapy

Quadruple therapy tetracycline Flagyl bismuth ppi

30

NSAID induced PUD

Gastric ulcers higher with old age higher dose steroids with NSAIDs give worse risk bleeding

31

ZE syndrome

Duodenal bulb, Gastrinoma's, present with PUD or diarrhea steatorrhea - inactivated pancreatic lipase
Diagnosis IV secretin increase gastric greater than 1000
CT scan or somatostatin receptor scan localized tumor
PPI and resection of Tumor
MEN1

32

G.I. bleeding monitor period

72 hours

33

Ppi related issues

C diff colitis, hospital acquired pneumonia, osteoporosis, hypomagnesemia, microscopic colitis

34

Esophageal varices

Not selective beta blockers such as propranolol carvedilol nadolol - if asthma then band ligation

35

Patient with cirrhosis and variceal bleed and spider angiomata

Nonselective beta blocker and antibiotics

36

Gastric malignancies

Adenocarcinoma 80% caused by h pylori

37

MALToma

Treat for H. pylori will regress

38

Post gastrectomy abdominal bloating postprandial symptoms relieved by vomiting

Afferent loop syndrome

39

Post gastrectomy fat and vitamin B12 malabsorption

Blinds loop syndrome bacterial overgrowth the conjugation of bike salts

40

Prognostic factor in acute pancreatitis

BUN - despite temperature elevated lactate white count no antibiotics

41

Congenital failure to fuse pancreatic ducts resulting in frequent pancreatitis

Pancreas divisum

42

Way to feed severe acute pancreatitis

Enterojejunal tube

43

Pancreatitis with muscle spasm in weakness

Hypocalcemia

44

18 Year old pancreatitis of unknown etiology

Sweat chloride test rule out cystic fibrosis - can be associated with pancreatitis

45

Lab values suggesting biliary ideology of pancreatitis

ALT greater than two times normal then increased alk phos

46

Severe pancreatitis elevated AST and LFT dilated common bile duct next

ERCP, remove stone, eventual cholecystectomy

47

Mild pancreatitis ultrasound gallstones no CBD dilation

Elective cholecystectomy

48

Post cholecystectomy patient with nausea vomiting pain chills with elevated bilirubin liver enzyme tests amylase

Retain common bile duct stone

49

Post hip replacements pain fever elevated liver enzymes elevated amylase ultrasound but thinking gallbladder wall

Acalculus cholecystitis requires cholecystectomy

50

Complications of pancreatitis

1.fluid collections pleural effusion's two days
2. Pancreatic necrosis less than two weeks
3. Pseudocyst wonder four weeks can hemorrhage rupture fistula
4. Abscess 4-6 weeks soap bubble sign Gram stain
5. Splenic vein thrombosis can occur anytime digastric CT abd

51

Ulcerative colitis

Rectal ulcer spreads proximately erythema friable mucosa very superficial ulcer crypto just toxic like a cool with erythema nodosum Rh negative arthritis pyoderma gangrenosum ankylosing spondylitis sclerosing cholangitis associated with cancer colonoscopy every after 8 years then q1-3

52

Crohn's disease

Rectal sparing perirectal fistulas anyone G.I. tract mainly in the terminal ileum skip lesions
Diarrhea deep ulcers with granulomas toxic Megacolon
String sign

53

Best treatment for stricture

Surgery

54

Ulcerative colitis with extraintestinal symptoms pain in joints of hands with early morning stiffness

Rheum neg arthritis - sulfasalazine

55

Diarrhea right lower quadrant mass temperature ulcer in mouth

Crohn's disease

56

Bloody diarrhea last 2 years, wks ago went to mexco, colonoscopy with erythematous friable mucosa

UC

57

Pt h/o UC with diarrhea/leukocytosis

r/o c diff

58

Young woman with chronic diarrhea wakes up at night for bathroom

Inflamm bowel dz

59

UC in remission - p/w LFTs bili, US shows focal dilations

ERCP/MRCP dx primary sclerosing cholangitis (beaded appearance) - brush bx prodominant stricture, need annual US gallbladder for polyps - if pos - cholecystectomy - if enzymes worsen then refer for liver tx

60

UC/Crohns maintenance medication

5ASA (Mesalamine +- flagyl, antiTNF alpha - DO NOT USE STEROIDS

61

Young man UC p/w abd pain, distension of colon to 7cm not improving with thumb printing on xray

subtotal colectomy

62

Pt with proctocolectomy and ileal anal anastamosis pouch p/w diarrhea with blood, temp -> endoscopy with diffuse superficial ulceration in pouch

Pouchitis -> tx with flagyl

63

Pt with Crohns rectovaginal fistula not responding to 6MP and flagyl

anti-TNF alpha (infliximab) - watch out for TB reactiv, PNA, crypto, histo

64

24 yo UC 4 years with jaundic and fever, hepatomegaly, elev bili, elev alk phos, AST, ALT p-ANCA +

Primary Sclerosing Cholangitis - beading/focal dilation biliary tree - P-ANCA +, a/w UC - if LFT/bili worsens - refer for liver tx

65

Review Chart GI page 453

Green book - GI

66

20 yo rectal bleed tenesmus - anal fissue - 6x6cm ulcer on leg

r/o UC with sigmoidoscopy/anoscopy - tx with 5asa suppostory

67

External hemorrhoid

topical NTG

68

Stool osmotic gap equation

290-2(stool Na+K)

69

Secretory diarrhea

>1L/day, doesn't stop with fasting, stool osm=290, osm gap <50

70

Osmotic diarrhea

50

71

longstanding diarrhea x years, stool osm 290, stool Na=50, K=25

lactose intolerance (stool gap >50)

72

diarrhea while vacation mexico - no blood, no fever

entertoxogenic e coli - tx with loperamide +- azithro x 3 days

73

Diarrhea +-fever +-blood with abd pain 2 days after undercooked poultry, mountain stream water, contact with dogs/cats - +fecal WBCs

C.Jejunum (can cause Guillion barre)

74

Diarrhea with abd cramping +- fever - had chicken, raw eggs or ice cream

salmonella

75

bloody diarrhea - hamburgers at fair 36hrs ago or unpasteurized mild - dec platelets

O157:H7 E.Coli - Mcorrey sorbitol agar - SX treatment only DO NOT GIVE ABX - will cause HUS - if RF then HD (TTP)

76

Bloody diarrhea

Shigella, C.jejuni, salmonella, c.diff

77

Diarrhea after camping, skiing with bloating, flatus, frothy stool

Giardiasis - check elisa for Giardia ag -> flagyl - post tx elisa should be negative

78

Canned Precooked foods beef/turkey - 12 hrs later diarrhea/vomitting no blood

C.perfringen - supportive tx

79

Diarrhea 4 hours after asian restaurant - fried rice - vomiting no blood

Bacilius cereus - supportive tx

80

Diarrhea after sea food dinner - g neg comma shaped bug

vibrio parhemolyticus -> cipro

81

Diarrhea, nausea vomiting, abd pain after eating fish (2hrs) with perioral paresthesias - reversal hot/cold sensation

ciguatera toxin from large reef fish (fish that eat other fish)

82

Flushing, utricaria, paresthesias minutes after eating fish

scromboid - histamine in fish

83

eats fish and minutes later parestehesias, weakness, ascendign paralysis and SOB

tetrodotoxin from puffer fish

84

Chronic diarrhea, hx travel to mexico last year - or presentation with acute dysntery - colonscopy with flask shaped ulcers

amoebic colitis

85

RUQ pain, fever, elev wbc after third world country - bloody diarrhea inc LFTs

amobic liver cyst - check stool for ova/cyts - elisa - if CT abd + then aspirate and tx with flagyl

86

HIV CD4<200 chronic diarrhea/wt loss no fever no blood

cryptosporidium - stool afb small round organisms - if stable just hydration, if not imporoving nitazoxanide

87

woman chronic diarrhea years, frequent small stools with mucous and constipation pain relieved with BM, no night waking no fever, wt loss anemia, stool studies neg, emotional stress - flex sig neg

irritable bowel syndrome (rome III criteria) - reassurance - rifaxinin, antispasmotics, anticholinergics - TCA, fiber

88

chronic diarrhea stool osm 300, stool Na 40, K 30 on adding naOH turns red

laxative abuse - stool gap 160 (>50)

89

diarrhea, RLQ pain, fever, rash fecal WBC no h/o diarrhea

yersinia enterocolitica

90

diarrhea WBC 12K Cdiff +

flagyl PO

91

recurred (x1) cdiff + diarrhea WBC 13

restart flagyl (leftover cdiff spores now matured)

92

recurred (x2) cdiff

vanco PO pulse therapy - 125mg 4x daily x 7 days, then taper

93

diarrhea, cdiff + WBC 18

po vanc (>15k don't use flagyl)

94

which abx induced B1/NAP1 cdiff which causes toxic megacolon

cephalosporin or quinalones

95

77yo M a/w PONA started on abx - what do prevent cdiff

probiotics (lactobacillus)

96

74yo known diabetic p/w diarrhea with c.diff WBC 12 better with flagyl returns with WBC 24 with hypotension, fever, tachycardia ele lacatate

po vanc, recta vanc, iv flagyl and surgery c/s

97

prevent spread of cdiff

wash hands with soap and water (no etoh sanitizer)

98

65yo M fatigue, chronic diarrhea, itching with pallor, bullous skin lesions, Hg low, MCV low, TIBC inc, ferritin low, occult neg - blood smear howel jowell body, colonscopy neg for bleed - no change with iron therapy

TTG ab r/o celiac sprue

99

If celiac sprue neg tx?

gluten free diet - can have dermatitis herpetiformis

100

Dermatitis herpetiformis tx

gluten free diet and dapsone

101

asx brother of pt with celiac sprue - what to check

HLA DQ2 or 8 (not TTG)

102

vitamin supplement needed in celiac sprue

Vit D

103

Diarrheal dz a/w celiac sprue

microscopic colitis

104

Pt with celiac sprue confirmed with TTG put on gluten free diet improves then worsens after few months

likely non-adherance

105

Pt with celiac sprue responds well to gluten free diet for 10 year now with diarrhea/abd pain/wt loss

r/o lymphoma

106

pt returns from 3rd world with diarrhea, foul oily stools, +steatorrhea, Hg low, MCV high D-xylose test abn, folic acid decreased

Small bowel bx - falttened villi with lymphotcitis and plasma cell infilitration - tropical sprue from klebsiella or ecoli -> treat with tetracycline and folic acid

107

25yo diarrhea, bloating, flatulance wt loss from dominican republic - low hg, high mcv low normal b12 +steatorrhea

tropical sprue - carribean folate N, B12 low, Asia folate low B12 N, Bact overgrowth folate high b12 low

108

Pt with diarrhea few months with greasy stools, fecal fat 15g/day, low d-xylose

check small bowel bx

109

pt with h/o arthritis>2yrs, diarrhea >3/day, oily stools, foul smelling, wt loss, adenopathy, SKIN PIGMENTATION, posterior uveitis with blurry vision - foamy macorphages and PAS+ on small bowel bx

Whipple's dz, t.whilli -> bactrim tetracycline

110

55yo with recurrent pain/swelling shoulers for years with wt loss, LAD and asp of knee with WBC 13K

PCR synovial fluid for t. whipplei (whipple's dz)

111

diarrhea with food intolerance, n/v/abd pain, steatorreha, ova/cysts/parasites neg -> peripheral eosinophilia

eosinophillic gastroenteritis - r/o parasitic infection then start steroids

112

35yo n/v epigastric pain for months - n/v in morning better with shower - wt loss but no dysphagia

marijuana induced

113

30yo F early satiety even with tiny amoutn of food for months - gastric emptying normal

tx with buspiron

114

chronic diarreha, fecal fat 14g/day, dxylose normal - B12 190, folate 18, small bowel shows diverticula

Bacterial overgrowth - check hydrogen breath test or xylose 14C breath test - tx with cipro+flagyl

115

Pt steatorrhea 40g/day, dxylose 8g/5hrs - colonoscopy normal, h/o lactose intolerance

xray abd check for Calcification of pancrease - chronic pancreatitis

116

Short bowel syndrome

calcium oxalate stones, replace ADEK, B12, Ca, Mg, Zn - replace long chain with med chain Fatty acids

117

Intestinal lymphangietctasia - dilated lymphatic vessels

replace long chain FA with med Chain FA

118

Abetalipoproteinemia

normal villi - impaired B globulin synthesis->imopaired chylomicron formation

119

pt s/p extensive small bowel resection with lots of diarrhea 3 days post op

PPI - acid induced diarrhea

120

small bowel resection of 50cm after GSW - diarrhea

mechanism is bile acid malabsorption

121

GSW with bowel resection - couple months later with greasy stools and wt loss - fecal fat 20g/day INR 1.2 dxylose nl,

etiology=decreased bile acids

122

severe ischemic colitis s/p small bowel resection - greasy stools wt loss, stool fat 20g/day, low alb/calcium

tx with med chain TG/FA

123

52yo F chronic watery diarrhea 5x daily no constip, blood, fever - neg stool studies, neg giardia, neg scopes

flex sig with bx - r/o microscopic colitis (collagenous) vs lymphcytic colitis (lymphocytes) - inflammation of laina propria (NSAIDs, PPI, setraline, DM can cause) - D/C offending agent - start budesonide - check TTG

124

Causes of osteomalacia

post gastrectomy, celiac sprue, biliary cirrhosis, pancreatic insufficiency, crohn's dz

125

60yo pt with fever, inc WBC, abd pain in LLQ

r/o diverticultis - CT scan - avoid colonoscopy/barium enema, cipro +flagyl - clear fluids then high fiber
4 weeks later do colonoscopy r/o cancer, crohns etc

126

treated diverticulitis 3 months later still wtih LLQ pain with no fever or WBC - left segmental diverticulosis - DX?

uncomplicated symptomatic diverticular disease - tx with mealamine, rifampin

127

Pt with divertiulitis with >4cm abscess

CT guided drainage first then elective surgery

128

pt with acute diverticulits and 9cm dilation with 5cm abscess

surgical intervention

129

what medication can cause divertiulitis with perforation

Tocilizumab - IL-6 inhibitor (also causes OCP failure)

130

75yo M with ER c/o painless brbpr, no pmhx - BP ok HR ok, BRB in rectal vault

dx - diverticulosis (painless)

131

55yo F with long rheum arthritis controled with ASA and naproxen x 14 years with abd pain for last 4 months - EGD/colonsocpy neg - small bowel barium enema with multiple concentric constricting lesions - dx?

small bowel diaphragm disease

132

Chronic mesenteric ischemic

post prandial, abd pain, fear of eating, wt loss - dec blodo from from PAD - dx with doppler us/angio, - tx with revascularization

133

Acute mesenteric ischemic

sudden onset sev abd pain, n/v/elev WBC, ileus - emboism in celiac, S mesenteric with valvular heart dz, afib, low flow state - dx with angio, tx with thrombolysis or surgery

134

Ischemic colitis

hematochezia, diarrhea, abd pain - low flow state (CHF, hypercoag state, hypotension) - dx with thumbprinting colon on xray, pausity of vessesl - rehydration and antibiotics

135

Angiodysplasia

AVM - cause lower GIB - common in elderly - osler weber rendu syndrome -> tx with laser photocaog, sclerotherapy or cautery

136

65yo M pmhx severe AS with recurrent melena - colonscopy with angiodysplasia

Aortic valve replacement

137

Post radiation tx in pelivs 2 years later with rectal bleeds - colonscopy with friable mucosa, atrophy and fibrosis - dx?

radiation prococolitis

138

70yo M with severe abd pain x 1 day, last BM normal - tender abdomen, h/o DM, CHF, HTN, JVD+, S3+ rectal normal , FOBT neg, amylase elevated - abd xray normal, CT abd with small bowel wall thickenss and intestinal pneumoatosis

check mesenteric angiography

139

MCC GIB in kids

meckels divertiulum

140

Constipation

BM<3x/wk, hyperCa+, hypothyroid, slow transic - pelvic floor dysfxn, CCB, HCTZ, anticholing, antipsych, opiates+stim laxative

141

Tx for constipation

tx underlying cuase and inc fiber

142

Opioid induced constipation

start laxative with opioid rx

143

elderly pt with chronic constip not responding to fiber

polyethylene glycol

144

Pt with stage IV lung Ca not responding to stimulant laxative, polyethylene glycol

SQ methylnaltrexone

145

elderly woman with constipation and diarrhea - hard stool in LQ

enema

146

65yo M s/p ortho surgery on abx and morphine - with abd pain adn distension - abd xray with 6cm distenstion of cecum with no WBC, hypokalemia

dx: acute pseduo colonic obstruction (ogilvie's syndorme) - CT scan or gentle hypaque (water soluble) enema to dx -> remove precip cause, correct electrolyties, d/c opiates, d/c aticholinergics, rectal tube, neostigmine

147

75yo F with LLQ pain x 2 days, last BM 1 wk ago, BS+, xray with colonic dilation, CT with partial obst of signmoid

Dx Sigmoid volvulus - flex sig (analgesia for pain won't affect dx accuracy)

148

Woman sharp RUQ pain x 1 year - severe - US/CT normla - pain with raising legs

FXN abd wall pain

149

Hepatitis A

RNA virus, incubation15-50 dyas, p/w jaundice, feco-oral/sexual, no carrier state, can worssen underlying liver dz (vacc HCV pts for HAV) - vaccinate high risk groups (travellors, gays, liver dz) - IVIG for high risk exposure -

150

Anti HAV IgM

Acute hep A -> treat!!

151

anti-HAV igG

post infection - Do not treat

152

Preg woman - how to determine past infection HAV

HAV IgG+, IgM-

153

Pt going to mexico for 2 weeks

hep A vaccine

154

Hep A vaccine in....

Hep C, chronic liver dz, high risk country travelor, gay men (NOT PT WITH PNA)

155

Pt returns from beize with contact with prostitutes - now with n/v/malaise, anorexia - HBV ab+, HBV cAb+ ->dx?

Hep A - check hep A serology in 2 weeks

156

Hepatitis B

only DNA virus in hepatitis - sexual or IVDA, 30% chance after needle stick - most pt clear infxn - lose HBsAg and get HBV Ab - 5% with chronic - 1% fulminant hepatitis
Causes cirrhosis - hepatoma 2-4%/year -> carrier status highest in infants

157

Heb B -> HBe Ag

denotes viral replication, active infxn

158

HBV Vacc

high risk groups

159

HBV IVIV (HBIG)

high risk exposure

160

HBV tx

interferon, tenofovir, entecavir, adefovir, lamivudine can suppress

161

HB S Ag

acute hep B, chronic hep B, Carrier Hep B

162

anti-HB cIgM

acute hep B

163

anti-HB c IgG

chronic, carrier, past infection

164

HB e Ag

active replication

165

Anti-HB IgG

post vacc, cleared infection

166

anti Hbc IgG Ab +, HBsAg neg Anti HBsAb neg

chrnoic hepatitis or past infection - HBsAg or Anti-HBs could be below threshold

167

pt low endemic area, no risk factors for Hep B has anti-HBc Ab only - wtd?

Hep B vacc

168

Nurse with HBV vacc with needle stick pt with HBV

check anti HBs Ab titer - if >10 - reassure, if <10 HBIG+booster HBV vacc

169

Pt with Hep B vacc series

+anti-HBs Ab

170

HBV DNA >20K, ALT normal - treatment?

none

171

HBV DNA >20K, ALT 1-2x normal - treatment?

Bx

172

HBV DNA >20K, ALT >2x normal - treatment?

Yes

173

HBV DNA >10IU - cirrhosis compensated

treat HBV

174

HBV DNA >10IU - cirrhosis decompensated

liver tx

175

HBV treatment

tenofovir, entecavir, telbivudine, adefovir, lamiudine or alpha interferon

176

HIV/HBV pt coinfected

if treating HIV also - tenofovir, otherwise alpha interferon

177

prior to starting rituximab or chemo with steroids or anti-TNF what to check

Hep B cIgG and HBsAg

178

Asian american woman with HBV in 3rd trimester - prevent HBV in child

telbivudine for mother and hep B vaccine/HBIG in baby

179

Hepatitis C

SSRNA - 90% tranfusion associated before 1992 - MCC of liver transplant in US, presentation with fatigue and elevated LFTs

180

Hep C high risk groups

IVDU/prisoners, blood tx before 1992, tattoos, snorting cocaine, most patients DO NOT CLEAR - NO VACCINE, NO IGG, no post exposure PPX available

181

Woman with hep C - precautions with husband

sex ok - DO NOT SHARE TOOTHBRUSH

182

60yo pt born 1945 to 1965 - what to check

hep C abs

183

Risk factors progression to cirrohisis from HCV

age>40, etoh, man, coinfection with Hep B or HIV

184

Treatment HCV

Boceprevir, interferon, ribavirin, d/c therapy if VLsuppressed

185

53yo M received multple blood tx in 1990 after MVA p/w fatigue, elev LFTs, Hep C Ab + and liver bx with mod bridging fibrosis - hep C viral load 250K - 2 months alater AST/ALT lower - VL 210K

Start IFN/ribavirin

186

Nurse gets stuck with needle HCV patient - Hep C ab neg

repeat HC Ab/RNA in 4 weeks (no ribavirin/IFN)

187

Nurse stuck with HCV 4 weeks ago with VL 45K - wtd?

reassess HCV RNA at 12 weeks if + start PI, ribavirin and IFN

188

Pt with IV exp to HCV 6 weeks later with malaise and fatigue - all Hep Ab neg - wtd?

check HCV RNA

189

55yo pt with fatigue, no history - ALT 2x, AST 1.5x, takes tylenol

Dx HCV (tylenol would be AST in 1000s) - if HCV Ab + check HCV RNA - if viral load high liver bx - if +fibrosis treat HCV (ribavirin+IFN)

190

Pt with hep C, genotype 1 on IFN, ribavirin p/w fatigue

check Hg (ribavirin causes hemolytic anemia) - if retic + then start erythropoietin, d/c ribavirin

191

If pt on IFN get depressed

start SSRI (Paroxetine)

192

Pt with HCV with briding fibrosis and inc'd HCV RNA started on Ribavirin and IFN - advice for pt

NO ETOH, if seroneg for HAV, HBV give vaccines for HAV/HBV

193

Extrahepatic manifestations of HCV

small vessel vasculitis, glomerulonephritis, neruopathy, mixed cryoglobulinemia dec C4>dec C3, porphyria cutanea tarda

194

HCV pt on ribavirin/IFN - what to monitor

hypothyroid, hyperthyroid

195

HDV

incomplete RNA virus needs HBV to survive

196

HBc IgM + HDV

Acute co-infection - doesn't make hepatitis worse

197

HBc IgG + HDV

Acute superinfection - can cause fulminant hepatitis

198

HEV

fecooral transmission like HAV, Fulminant hepatitis in 3rd trimester of preg, ALL hepatitis seriology NEGATIVE,

199

Tylenol liver damage

>7g tylenol can cause liver damage, in etoh 4gm tylenol causes liver damage - N-acetylcystein antidote

200

20yo took 30 gm pain pill - ER denies sx - tylenol level Pending - wtd

give oral n-acetylcysteine without waiting for labs - if within 1hr then gastric lavage, activae charcoal and syrup of ipepac

201

heavy etoh with myalgias and ha took tylenol q4h for past couple days now with n/v/abd pain AST 11,000, ALT 9000 INR 3 - dx?

acetaminophen toxicity

202

INH Hepatitis

Dose related, age related tox with inc AST/ALT, ANA+

203

Hepatitis with cholestasis

amox-clavu, bactrim, erythromycin

204

Hepatitis with macrovascular fatty change

etoh hepatitis, amiodarone, steroids

205

Hepatitis with microvasicular fatty change

tetracycline, reye's syndorme with ASA+flu

206

Chronic drug hepatitis

methyldopa, trazadone, nitrofurantoin, phenytoin

207

Direct liver toxicity

tylenol

208

Dysphagia

Solids -> pogressive Age>50 -> carcinoma
Solids -> progressive -> heart burn -> peptic stricture -> EGD/bx r/o CA ->dilation/PPI
Solids-> intermittent -> esosinophilic esophagitis -> esoph rings (steakhouse syndrome)
Solids or liquids ->progressive->cough/regurg ->achalasia->dx with barium swallow (autoimmune)
Solids or liquids->progressive->heart burn->scleroderma (scl70)
Solids or liquids->intermittent->chest pain -> diffuse esophageal spasm -> corkscrew esophagus->PPI trial->confirm with manometry

209

Pt with intermittent syphagia to solids and liquds w/ CP

DES -> barium swallow (cordscrew esophagus)-> confirm with manometry-> PPI if no response-> CCB

210

Young pt with steak dysphagia -> first bite ->

esophageal rings/schatzky ring-> pneumatic dilation

211

food regurg several hours after eating, no heartburn, dyphagia to solids and liquids - dilated esophagus with tapering (bird beak) - manometyr decreased peristallsis increased Lower esoph pressure

Achalasia -> surgical myotomy (EGD r/o lymphoma or cancer

212

GERD

Acid reflux sx - CP, heartburn, nocturnal cough, asthma, dental erosion

213

GERD complications

Barrett's-> AdenoCA

214

GERD Tx

wt lossw, head elevation, tob cessation, early dinner, PPI>H2, fundoplication

215

GERD EGD indication

heart burn not relieved with PPI x 8 wks, heartburn >5years, heartburn with wt loss, melena, anemia, dysphagia/odynophagia

216

Hearburn partial response to PPI but EGD with severe GERD

lap fundoplication - prior to procedure manometry to confirm esophageal motility - (otherwise iatrogenic achalasia cuased)

217

elderly pt with GERD not responsing to H2 - EGD with stricture dilated - bx neg, prox gastritis - further managment

lifelong PPI

218

Barretts

normal Gastro-esoph jnc squamous epithelium - changes to columnar epithelium (like stomach) -> strictures/adenoCA

219

gastritis

Erosive - NSAIDS, etoh, burns, surgery, vent, - tx with H2, PPI
Chronic type A - fundus/body less common - atrophic gastritis - inc gastrin
Chronic type B - antrum more common - cause by h pylori, tx H pylori only with sx

220

PUD causes

H. pylori, NSAIDS, ZE

221

H. Pylori

gram neg urease producing, inc'd in 3rd world, PUD, type B gastritis, gastic CA, maltoma,

222

45yo Fp/w itching esp at night +xanthomas, alk phos 1400, +AMA, -ANA, liver bx granulomas/lymphocytic destruction of bile ducts (dec ADEK, osteomalacia, HLD with high HDL)

Primary biliary cirrhosis (PBC) - tx ursodeoxycholate (delays progression, doesn't prevent --> liver transplant

223

Autoimmune hepatitis

young woman with fatigue, wt loss, arthralgia, acneform rash, amenorrhea, +icterus, AST/ALT inc 5-10x, inc globulins, (a/w thyroititis, ITP, anemia, Coombs+) -> +ANA, +ANCA, +Anti DSDNA, +SMA (most specific)
Bx - piece meal necrosis of hepatocytes,
Tx - prednisone/azathioprine - NO IFN (makes worse)

224

25yo F juandice, ALT 350, alkphos 115, +ANA, +ASMA, -AMA, IgG elev -> liver bx piecemeal necrosis of hepatocytes

Autoimmune hepatitis

225

26yo F jaundice, ALT 40, alk phos 290, -ANA, -ASMA -AMA, IgM/G normal - Liver bx mild inflamm with concentric fibrosis around bile ducts

Primary Sclerosing cholangitis (extrahep duct fibrosis) - urosdiol doesn't help

226

26yo F jaundice, ALT 100, alk phos 550, ANA neg, ASMA neg, AMA pos, IgM elev, IgG normal, liver bx - lymphocytic destruction of bile ducts

Primary Biliary cirrhosis (intrahep bile duct destruction, elev alk phos) - ursodiol helps

227

Etoh Liver dz

Fatty liver-> etoh hepatits-> micronodular cirrhosis - hepatomeg, fat vaculoles on liver bx (reversible with stopping etoh)

228

Etoh hepatitis

aorexia, n/v/abd pain/wt loss - AST:ALT 2>1, AST ALT up to 300, Hepatomegaly, liver bx - necrosis of hepatocytes with inflamm cells, inc WBC, enceph, elev PT

229

35yo F jaundice, confusion, malaise, RUQ pain - icterus, mild ascities, hepatomegaly, AST 200/alt 100, INR 1.5, WBC 18, bili 15

acute etoh hepatitis -> steroids if no bleed

230

If acute etoh hepatitis with bleed

pentoxyfyline

231

Obese pt DM, HLD - non-etoh - mild elev of ALT/AST 2:1, Fasting suger 160, chol 280 - liver bx fatty changes with some fibrosis

NASH - dx wit liver bx - tx underinglying weight, DM, vit E, statin

232

Causes of cirrhosis

Viral (B,C,D), Autoimmune hepatitis, etoh, PBC, PSC, Hemochormatosis, wilsons, CHF/Budd chiari (stasis)

233

CA screening with cirrhosis

liver US/ alpha feto protein

234

MELD

PT, INR, Ser Cr, Ser Bili
MELD24 - liver tx

235

Indication for liver tx

viral hep, autoimmune hep, PBC, PSC, hepatoma, wilsons, Alpha 1 AT def, fulmianent hep failure

236

Contraindications

untreated HIV, extrahep CA, active etoh/drug use, unresolved sepsis/fungemia, Hep B with eAg +

237

When to refer for liver tx

cirrhotics with clinical or biochemical decompensation

238

Pt with cirrhosis p/w hep enceph - quit drinking 2 years ago, ascitic fluid WBC 70 - wtd

refer for liver tx

239

SAAG

figure this out

240

Least likely to cause chylous ascites

cirrhosis/CHF

241

management of cirrohsis with ascites

Na restriction to 1g/day, fluid restriction, diuresis witih aldactone/diurteics - large volume paracentesis or TIPS

242

Cirrhotic p/w elev WBC, fever, ascities

paracentesis

243

Pt with long cirrhosis brought in with lethargy, asterixis and asciteis - PT INR 3, plt 40 - WTF

paracentesis (plt>30 - ok)

244

SBP

PMN >25 in asciteis or WBC >500 with >50%pmn

245

SBP tx

cefotaxime (3rd gen cephalo) - usually single organism (ecoli, kleb, s pneumo) - give albumin if Ser Cr elev or bili >4

246

Post surgery NPO OR pt on abx for bronchitis get icterus - AST/ALT normla, alk phos nromla - indirect bili elev 4.2, direct bili 0.3 - 2 days later total bili 2.5

Gibert's syndrome - no tx

247

Wilson's dz

autosom recessive - chronic hepatitis with elev LFTs, nuero sx (tremors, rigidity, psych (personality/behavor), heolytic anemia - copper accumulation in liver/body tissues - urine copper high - KAYSER-FLEISCHER RING - liver bx with copper

248

Tx wilson's dz

chelation penicillamine/pyridoxine -> severe dz - liver tx

249

UGIB causes

PUD, varices, mallory weiss tear, splenic vein thrombosis

250

Pt with coffee ground emesis and dizzinesss - NGT with blodo tinged fluid - BP 90/60 HR 120

fluid resucitation

251

Acute UGIB, continues bleeding confused, hypotensive/tachy

intubate then scope after volume resusitation

252

Point to transfuse UGIB

<7gm Hg

253

Tx of UGIB

bleeeding ulcer - electrocautery, visible vessel monitor/electrocautery, bleeding varices - octreotide infusion with banding -> monitor for 72hrs

254

Clean based ulcer no bleed

early feeding

255

PPI use

rel to cdiff, HAP, osteoporissis, low Mg, microscopic colitis

256

prevent rebleed in PUD

PPI