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Flashcards in Gastroenterology Deck (184):
1

Tx. partial small bowel obstruction

observation and supportive therapy - IVF, NG suction, electrolytes

2

first test for dysphagia

barium swallow

3

what does odynophagia suggest?

infectious process such as HIV, HSV or Candida

4

progressive dysphagia to both solids and liquids with occasional regurgitation of food particles and aspiration - dx?

achalasia

5

best initial test: achalasia

barium swallow

6

most accurate test: achalasia

esophageal manometer
- absence of normal esophageal peristalsis
- high pressure at LES

7

best initial therapy: achalasia

surgical myotomy
- alt. pneumatic dilation

8

when do you use wireless video endoscopy

small bowel disease only
- limited views of esophagus and stomach
- very high resolution

9

presentation of esophageal ca.

dysphagia for solids first, then liquids
heme positive stool or anemia
usually pt > 50 who smokes and drinks

10

best initial test if suspected esophageal ca.

endoscopy
- if not an option: barium swallow

11

best initial therapy: esophageal ca.

surgical resection (if no local or distant mets)
F/U surgery with 5-FU based chemotx

12

proximal esophageal stricture in iron-deficient middle aged woman

Plummer Vinson syndrome
- may be assoc. with SCC

13

best initial therapy: Plummer Vinson

iron replacement

14

distal esophageal ring that presents with intermittent symptoms of dysphagia; it has no malignant potential --> DX? Best initial therapy?

dx. Schatzki ring
best initial therapy - pneumatic dilation

15

pt with dysphagia and regurgitation of food; pt has bad breath - dx? best initial test?

Zenker diverticulum
best initial test: barium swallow

16

best initial therapy: Zenker diverticulum

surgical resection

17

what two procedures are C/I in Zenker diverticulum?

endoscopy
NGT placement
- high risk of perforation

18

pt presents with severe chest pain of sudden onset after drinking a cold beverage. EKG is WNL. DX? best initial test

dx. diffuse esophageal spasm
best initial test: esophageal manometry

19

tx. esophageal spasm

CCBs and nitrates

20

HIV pt with CD4 < 100 presents with odynophagia - next step?

empiric fluconazole
- endoscopy only done if no response to fluconazole

21

next step in HIV negative pt who presents with odynophagia

endoscopy

22

pt presents with severe chest pain after several episodes of vomiting. He is dyspneic and the pain radiates to his shoulder - dx?

Boerhaaves syndrome - esophagael perf

23

Dx. Boerhaaves

esophagogram with water soluble contrast
- do NOT do EGD

24

pt presents with upper GI bleeding following vomiting episode - dx? best initial test?

mallory weis tear
- dx test: EGD

25

Tx. mallory weiss tear

most cases resolve spontaneously
- if bleeding persists, Epi injection can be used to stop the bleeding

26

CF of GERD

chronic cough/wheezing
sore throat
hoarseness
bitter/metallic taste

27

Best initial management of GERD

PPIs - both diagnostic and therapeutic
- 24 hour pH monitoring should only be done if there is no response to PPIs and the diagnosis is not clear

28

when do you need to do an EGD for pt with GERD?

1. alarm symptoms - dysphagia, weight loss, anemia, heme positive stool
2. symptoms of reflux > 5-10 years

29

endoscopic finding of barret's esophagus - action?

PPI
repeat endoscopy Q2-3 years

30

endoscopic finding of low grade dysplasia of esophagus - action?

PPI
rpt endoscopy in 3-6 months

31

endoscopic finding of high grade dysplasia of esophagus - action?

endoscopic mucosal resection, ablative removal or distal esophagectomy

32

MCC of epigastric discomfort

non-ulcer dyspepsia
- diagnosis of exclusion

33

Tx. non ulcer dyspepsia

PPis

34

what needs to be done in any patient > 45 yo with epigastric pain?

EGD

35

management of H.pylori infection

PPI + clarithromycin + amoxicillin
(alt. PPI + metronidazole + tetracycline)
- only treat h.pylori if it is associated with gastritis or ulcer disease

36

RF for stress ulcers

head trauma
mechanical ventilation > 48 hrs
burns
coagulopathy and steroid use in combo
sepsis
ICU > 1 week
occult GI bleed > 6 days

37

prophylaxis for stress ulcers

if enteral - use PPI
if IV - use H2 blocker

38

do you need to treat finding of h.pylori if no gastritis or ulcer disease?

no - if having epigastric pain, may give PPI

39

multiple ulcers that persist with treatment for h.pylori - what should you order next?

gastrin level and gastric acid output testing

40

elevated gastrin level

1. Zollinger Ellison
2. anyone on a PPI or H2 blocker

41

lab findings in Zollinger Ellison syndrome

gastrin level elevated
gastric acid output elevated

42

most accurate test for zollinger ellison

secretin stimulation test
- normally, gastrin and gastric acid output decreases with secretin; with ZES, there is no change or an increase

43

diagnostic tests for ZES

endoscopic ultrasound
nuclear somatostatin scan
secretin stimulation

44

tx, local ZES

surgical resection

45

tx. metastatic ZES

PPIs lifelong

46

ASCA and ANCA results in Crohns vs. UC

Crohns: ASCA +, ANCA -
UC: ASCA - , ANCA +

47

screening colonscopy in IBD

perform Q1-2 years after 8-10 years of colonic involvement

48

best initial therapy for either CD or UC

mesalamine

49

adverse effects of sulfasalazine

rash
hemolytic anemia
interstitial nephritis

50

what steroid can be used to control acute exacerbations of IBD ?

budesonide

51

what drugs are used in pts with severe, recurrent IBD despite being on steroids?

Azathioprine and 6 mercaptopurine

52

when is infliximab useful for tx IBD?

Crohns disease that is associated with fistula formation

53

what antibiotics are useful for perianal involvement in Crohns?

metronidazole and ciprofloxacin

54

MCC of food poisoning

campylobacter

55

best initial test for infectious diarrhea

fecal leukocytes

56

most accurate test for infectious diarrhea

stool culture

57

What makes infectious diarrhea "severe"

blood
fever
abdominal pain
hypotension and tachycardia

58

tx. severe infectious diarrhea

FQ - cipro

59

Dx. giardia

stool ELISA antigen

60

Tx. giardia

metronidazole or tinidazole

61

diarrhea in HIV positive patient with CDC < 100 - dx? test? tx?

dx. cryptosporidum
test: modified acid fast stain
tx: antiretrovirals to raise CDC, paromomycin or nitazoxanide

62

pt goes out to eat seafood and within 10 minutes of finishing his tuna he begins vomiting and has diarrhea, skin flushing and wheezing - dx? tx?

scombroid
- tx. with antihistamines

63

tx. mild C.diff (WBC < 15,000, Cr < 1.5x)

PO metronidazole

64

tx. severe C. diff (WBC > 15 000 and Cr > 1.5x baseline)

PO Vancomycin

65

When would you have to do surgery to treat C.diff (subtotal colectomy)?

WBC > 20 000
Lactate > 2.2
Toxic megacolon
Severe ileus

66

Alternative treatment to vanco for severe, recurrent C.diff

Fidoxamicin

67

what should you do if you have a strong clinical suspicion of C.diff but lab studies are negative?

limited colonoscopy or flexible sigmoidoscopy

68

Causes of fat malabsorption and steatorrhea

Celiac dz
Tropical sprue
Whipples disease
Chronic pancreatitis

69

Associated findings with fat malabsorption

Hypocalcemia (vit d deficiency)
Oxalate over absorption with Oxalate stones
Easy bruising and elevated PT/INR
Vitamin b 12 malabsorption

70

Best initial test for malabsorption

Sudan black stain of stool

71

Most sensitive test for malabsorption

72 hour fecal fat

72

What nutritional deficiencies are unique to malabsorption due to celiac dz

Iron deficiency
Folate deficiency

73

Best initial test for celiac disease

Antigliadin antiendomysial and anti tissue transglutaminase abs

74

Most accurate test for celiac dz

Small bowel biopsy
- always needs to be done to exclude bowel lymphoma

75

Tropical sprue

Pt presents like celiac disease but there will be a history of travel and the antibody tests will be negative

76

Tx, tropical sprue

Tetracycline or TMP-SMX for 3-6 months

77

How does Whipple disease present?

Fat malabsorption diarrhea with arthralgias, neurological abnormalities and ocular findings

78

Most accurate diagnostic test for Whipples disease

Small bowel biopsy showing PAS positive organisms
Alternate: PCR of stool for trophyerema whippeli

79

Tx. Whipples disease

Tetracycline or TMP-SMX for 12 months

80

Amylase and lipase levels in chronic pancreatitis

Normal

81

Best initial tests for diagnosing chronic pancreatitis

Abdominal XR
Abdominal CT scan without contrast

82

Most accurate test for diagnosis of chronic pancreatitis

Secretin stimulation test
- normally, secretin causes large volume of bicarbonate rich pancreatic fluid secretion (decreased or absent in chronic pancreatitis)

83

What tests should you order on CCS in pt with suspected IBS

Stool guaic, white cells, culture, ova, parasite exam
Colonoscopy
Abdominal CT scan

84

screening for CRC if one family member had CRC

at age 40 or 10 years before the age of the family member - whichever one comes first

85

CRC screening if 3 family members, two generations and one premature form in history

every 1-2 years starting at age 25

86

CRC screening for FAP

sigmoidoscopy starting at age 12

87

usefulness of CEA marker in CRC

never for screening - used to follow response to therapy

88

LLQ pain with lower GI bleeding should make you think of..

diverticulosis

89

best diagnostic test for diverticulosis

abdominal CT

90

most accurate test for diverticulosis

colonscopy

91

Tx. diverticulosis

high fiber diet

92

CF: diverticulitis

LLQ pain
tenderness
fever
elevated WBC count

93

best diagnostic test for diverticulitis

abdominal CT scan
- confirmatory: shows thickening of bowel wall
- colonoscopy and barium enema are C/I

94

Tx. diverticulitis

IV antibiotics
1. Ciprofloxacin and metronidazole
2. Cefoxitin
3. Cefuroxime and metronidazole

95

common complication of diverticulosis

colovesicular fistula - causes pneumaturia

96

diseases that are associated with angiodysplasia

ESRD
Von Willebrand dz
aortic stenosis

97

most urgent step in management of severe GI bleeding

fluid resuscitation

98

orthostasis in GI bleeding

drop of > 20 mmHg in systolic pressure OR increase in pulse by > 10 /min implies >30% volume loss --> hemodynamic instability

99

CCS - what do you order for large volume GI bleeding?

bolus of normal saline
CBC
PT/INR
Type and cross
GI consult
EKG

100

when do you transfuse PRBCs in GI bleeding?

if Htc < 30 in older person; < 20-25 in young otherwise healthy person

101

when do you transfuse FFP in GI bleeding?

prolonged PT/INR

102

MCC of death in GI bleeding

myocardial ischemia

103

pt with GI bleeding and presence of ulcer disease - what should you add to managment?

PPI

104

Tx. variceal bleeding

1. octreotide
2. upper endoscopy w/ banding
3. if bleeding persists despite time --> consider TIPs

105

Pt presents with abdominal pain, bloody diarrhea and hypotension. During workup, a colonscopy shows patchy areas of depigmented mucosa - dx? tx?

Ischemic colitis
- if transmural, the mucosa will be sloughing and green
tx. IVF, bowel rest

106

when do you use a technetium bleeding scan

performed to detect site of bleeding if endoscopy does not reveal a source

107

when do you use capsule endoscopy in GI bleeding

if upper and lower endoscopy cannot reveal a source

108

Tx. acute pancreatitis

IVF
IV narcortics
IV abx - only if necrotizing pancreatitis

109

Antibiotic of choice in severe necrotizing pancreatitis (suspect when pt with pancreatitis spikes a fever)

Imipinem
- also: 3rd gen ceph, piperacillin, FQs, metronidazole

110

Tx. mallory weiss tear that is not actively bleeding

observation and supportive care

111

what anatomical predisposing factor is seen in Mallory-Weiss syndrome

hiatal hernia (10-40% of pts)

112

standard caloric intake for enteral feeding

30 kcal/kg/day with 1 g/kg/day of protein

113

Dx. SBP

1. ascites PMN count > 250 /mm3
2. positive ascites culture or stain (usually E.coli, strep and rarely, staph)

114

Tx. SBP

3rd gen. ceph (cefotaxime)

115

Dx. diverticulitis

Abdominal CT scan
- colonic wall thickening, stranding of mesenteric fat

116

Tx. mild diverticulitis

outpatient Ciprofloxacin + Metronidazole

117

dyspepsia

chronic/recurrent pain or fullness in the epigastric area without significant heartburn

118

confirmation of eradication of H.pylori

fecal antigen test or urea breath test - 4 weeks after completion of therapy

119

for whom should you confirm eradication of h.pylori?

duodenal ulcer
persistent dyspepsia
MALToma
resection of early gastric ca

120

Indications for biliary drainage in acute cholangitis

1. persistent abdominal pain
2. hypotension despite aggressive fluid resuscitation
3. fever > 39C
4. mental confusion

121

pain on an empty stomach

duodenal ulcer

122

CF of chest pain assoc. with GERD

1. squeezing/burning pain that radiates toward back, neck, jaw and arms
2. may resolve spontaneously or after antacids
3. occurs postprandially
4. awakens pts from sleep
5. worsens with emotional stress

123

Side Effects of Isotretnoin

hypertriglyceridmia (acute pancreatitis)
mucocutaneous lesions
myalgias
hyperostosis
pseudotumor cerebri
night vision troubles
BM suppression
hepatotoxicity

124

Tx. Toxic Megacolon

1. ICU admission
2. NGT
3. Glucocorticoids
4. IVF and electrolytes

125

which two drugs should not be used in toxic megacolon?

1. opiates
2. 5ASA compounds

126

two most common causes of massive colonic bleeding

angiodysplasia
diverticulosis

127

source of bleeding in diverticulosis

ruptured vasa recta either at apex or neck of
diverticulum (erosion of the artery)

128

associations with angiodysplasia

aortic stenosis
ESRD

129

manometric findings in scleroderma

absence of peristaltic waves and decreased LES tone

130

Classic symptoms of sclerodermal esophageal dysmotlity

sticking sensation in throat accompanied by heartburn

131

s/e: kava

liver toxicity - hepatitis, cirrhosis, liver failure

132

lactose breath hydrogen test

Pt should fast for 8 hours prior to test, consuming no food and water; then asked to drink lactose-containing beverage and breath into a bag. Increase in breath hydrogen conc. > 20 ppm is suggestive of lactose intolerance

133

what other screening test should be done when FAP is diagnosed?

screening upper endoscopy
- gastric and duodenal adenomas/carcinomas are MC

134

serum sickness-like syndrome in prodromal phase of Hep B infection

Type 3 reaction (circulating immune complexes)
- fever, rash, arthralgias
- polyarteritis nodosa
- glomerulonephritis

135

splenic vein thrombosis

isolated gastric varices as a complication of chronic recurrent pancreatitis; may also have massive splenomegaly

136

portal vein thrombosis

esophageal and gastric varices

137

management of swallowing issues in ALS pts

insertion of PEG tube
- does not lead to development of sinusitis and does not affect the patients breathing or speech

138

Drugs that can cause pancreatitis

1. Diuretics - furosemide, thiazides
2. IBD - 5ASA, sulfasalazine
3. Immunosuppresives - azathioprine, L-asparaginase
4. Seizures/ bipolard - valproic acid
5. AIDs - didanosine, pentamidine
6. abx - metronidazole, tetracycline

139

Dx. acute mesenteric ischemia -most accurate test

angiography

140

CF: acute mesenteric ischemia

severe abdominal pain
metabolic acidosis
elevated amylase level

141

Management approach to acute mesenteric ischemia

1. Plain film
- if negative: assess risk of hypercoagulability
LOW risk = are there peritoneal findings?
- yes: laparotomy
- no: angiography
HIGH risk = dynamic CT

142

Tx. acute mesenteric ischemia

surgical resection of the bowel - surgical emergency

143

Pt with history of gastric surgery presents with shaking, sweating, weakness and hypotension following meals. Dx/ Management?

Dx. Dumping syndrome
Tx. small frequent meals (low carb, high protein/fat)
- trial of somatostatin

144

Dx. diabetic gastroparesis

1. R/O mechanical obstruction and extrinsic compression with upper endo or CT/MRI respectively
2. confirmatory test: nuclear gastric emptying study

145

Tx. diabetic gastroparesis

smaller meals with less fat content
Tx. erythromycin or metoclopramide

146

acute pancreatitis
- best initial test (1)
- most accurate test (2)

1. amylase and lipase serum levels
2. abdominal CT

147

when is MRCP used for acute pancreatitis?

it can detect causes of biliary and pancreatic duct obstruction not found on CT scan

148

when is ERCP used for acute pancreatitis?

when you have common bile duct dilation without a pancreatic head mass; can be used to detect and remove stones from the pancreatic bile duct system

149

what urinary test can be used to detect the severity of pancreatitis?

trypsinogen activation peptide

150

management acute pancreatitis

1. NPO - if > 48 hours, consider NJ feeds with high protein, low fat meals
2. hydration
3. medications

151

scoring system for severity of acute pancreatitis

APACHE II criteria
- most precise method: CT scan

152

if CT scan shows necrosis of pancreas - what do you do

abx - imipenem
CT guided biopsy - if infected/necrotic, pt requires surgical debridement of pancreas

153

what other condition is hep B associated with? hep c?

hep B = PAN
hep C = cryoglobulinemia
- both can present like a serum-sickness (joint pain, uriticaria, fever)

154

which LFT is elevated in viral hepatitis? drug-induced hepatitis?

viral = ALT
drug induced = AST

155

what is the first test to become abnormal in Hep B

surface antigen

156

dx. chronic hep B

presence of surface antigen for > 6 months

157

what is the only antibody present during the window period of hep B infection

core antibody

158

when should babies born to hep B positive women get serology controls?

3-4 months after last vaccine dose

159

hep C
- best initial test (1)
- most accurate test (2)

1. hep C antibody - cannot distinguish between persistent, cleared of FP result
2. hep C PCR for RNA
- determines activity of disease and response to therapy

160

when do you use liver biopsy in hep C

most accurate way of determining seriousness of disease; determines extent of liver damage

161

Tx. chronic hep B

lamivudine
adefovir
entecavir
telbivudine
tenofovir
interferon

162

tx. chronic hep C

interferon + ribavirin and boceprevir or telaprevir

163

S/E: Interferon

flulike symptoms
arthralgia
myalgia
fatigue
thrombocytopenia
depression

164

MC adverse effect of ribavirin

anemia

165

postexposure prophylaxis of hep C

none

166

Hepatorenal syndrome

pt with cirrhosis presents with Urine Na <10 with no increase in urine output with a fluid challenge; Tx. liver transplant

167

Tx. encephalopathy 2ndary to cirrhosis

lactulose

168

Tx. ascites 2ndary to cirrhosis

spironolactone

169

Management: esophageal varices in cirrhosis

1. if bleeding --> banding
2. should receive prophylactic abx (Cipro) prior to banding
3. prophylaxis --> propranolol

170

when should you get a paracentesis in cirrhosis

1. new onset ascites
2. pt with ascites and pain, fever or tenderness

171

serum to ascites albumin gradient

> 1.1 indicates portal HTN from cirrhosis or CHF

172

Tx. SBP

Cefotaxime
- follow up prophylaxis with levofloxacin

173

MELD scoring system

determines 90 day mortality in pts with advanced liver disease based on INR, serum bilirubin and serum Cr levels

174

middle aged woman comes in itching skin and xanthelasmas. She has a history of hypothyroidism. Labs show elevated ALP. Dx? Most accurate test? Tx?

Dx. primary biliary cirrhosis
Test: antimitochondrial ab, liver biopsy
Tx. ursodeoxycholic acid

175

patient with IBD presents with itching skin and jaundice. labs show elevated ALP. Dx? Most accurate test? Tx?

Dx. primary sclerosing cholangitis
Test: antismooth mm ab, ERCP (beading), ANCA positive
Tx. ursodeoxycholic acid

176

dx. Wilson's disease

initial - Slit lamp exam, low ceruloplasmin level
most accurate: liver biopsy

177

Tx. Wilson's disease

penicillamine
trientine

178

MCC of death in hemochromatosis

cirrhosis

179

CF: hemochromatosis

restrictive CM
skin hyperpigmentation
joint pain --> pseudogout (2nd/3rd MCP, polyarthritis)
diabetes
panhypopituitarism
infertility
hepatoma

180

best initial tests for hemochromatosis

elevated serum iron and ferritin
low TIBC
transferrin sat > 50%

181

confirmatory test hemochromatosis

1. liver biopsy
2. MRI of liver + HFE gene mutation

182

Tx. hemochromatosis

phlebotomy

183

best initial tests for autoimmune hepatitis

ANA
anti-smooth mm ab
SPEP = hypergammaglobulinemia

184

Tx. autoimmune hepatitis

prednisone