Gastroenterology Flashcards

Question

What should you do if a patient has diarrhea?

Answer 1

watch for and treat **dehydration** and **electrolyte ∆s**, especially **metabolic acidosis** and **hypokalemia** Do a **rectal examination**, **look for occult blood in stool**, and **examine the stool** for bacteria (Gram stain and culture), ova and parasites, fat content (steatorrhea), and white blood cells.

Answer 2

watch for **hemolytic uremic syndrome**, which is characterized by: * thrombocytopenia * hemolytic anemia (schistocytes, helmet cells, and fragmented red blood cells on peripheral blood smear) * acute renal failure Treatment: supportive; may need dialysis and/or transfusions

Answer 3

Both forms of IBD can cause: * uveitis * arthritis * ankylosing spondylitis * erythema nodosum * erythema multiforme * primary sclerosing cholangitis * failure to thrive or grow in children * toxic megacolon * Toxic megacolon is more common in UC; look for a markedly distended colon on abdominal radiograph. * anemia of chronic disease * fever

Answer 4

5-aminosalicylic acid +/- sulfa drug (e.g., sulfasalazine) when stable Steroids + immunemodulators (azathioprine) during severe disease flare-ups

Answer 5

classically seen with IBD (especially UC) and infectious colitis (especially C. difficile) may be precipitated by **antidiarrheal medications**, which for this reason are usually not given for infectious diarrhea presentation: high fever, leukocytosis, abdominal pain, rebound tenderness, and a dilated segment of colon on abdominal xray treatment: discontinue all antidiarrheal meds; make NPO, place NGT, start IV fluids, give antibiotics to cover bowel flora (ceftriaxone plus metronidazole) + steroids if the cause is IBD. Surgery indicated if perforation occurs.

Answer 6

* Elevated liver function tests (AST, ALT, bilirubin, alkaline phosphatase, and/or PT/INR) * Jaundice * Nausea and vomiting * RUQ pain or tenderness * Hepatomegaly

Answer 7

* Alcohol * Medications * Infection (usually hepatitis) * Reye syndrome * Biliary tract disease * Autoimmune disease

Answer 8

An elevated AST that is more than twice the value of ALT, although both may be elevated.

Answer 9

Look for outbreaks from a **foodborne** source. **IgM anti-hepatitis A virus (HAV)** is positive during jaundice or shortly thereafter. The incubation period is about **4 weeks**, although IgM may be detected by the time symptoms begin.

Answer 10

perinatally, sexual transmission, contaminated needles, transfused blood IFNa-2b, peg-IFNa-2a, adefovir, dipivoxil, entecavir, telbivudine, or tenofovir can be tried in patients with chronic hepatitis and elevated liver enzymes.

Answer 11

hepatitis B surface antigen (HBs**Ag**) is (+) with any *_unresolved_* infection (acute or chronic) (+) HBs**Ab** means that the patient is immune (as a result of either recovery from infection or vaccination); HBsAb never appears if the patient has chronic hepatitis. hepatitis B “e” antigen (HBe**Ag**) is a marker for infectivity patients with hepatitis B “e” antibody (HBeA**b**) have a low likelihood of spreading disease. The ***first antibody to appear is the IgM hepatitis B _core_ antibody*** **(HBcAb)**, which appears during the **“WINDOW PHASE”** when ***both HBsAg and hepatitis B surface antibody (HBsAb) are negative.***

Answer 12

Cirrhosis and hepatocellular cancer (only with chronic, not acute, infection).

Answer 13

Hepatitis B Ig + hepatitis B vaccination or hepatitis B vaccination alone BOTH been demonstrated to be effective in preventing transmission after exposure to hepatitis B virus.

Answer 14

**Hepatitis C** * most likely cause of hepatitis after a blood transfusion * more likely than hepatitis B to progress to chronic hepatitis, cirrhosis, and cancer. Because of the relatively high prevalence in the “baby boomer” generation and lack of symptoms, the CDC and Prevention has recommended that **all Americans born between 1945 and 1965 have a one-time screening test for hepatitis C.**

Answer 15

**(+) hepatitis C antibody** means that the patient has had an infection in the past, but does *_not_* mean the infection has been cleared. Many patients become chronic carriers of the virus. A test for **hepatitis C virus RNA** can detect and quantify the virus. Treatment: **pegylated IFNa** + **ribavirin** (plus a protease inhibitor for those with genotype 1) * Success rates depend on the type of infection: Genotype 1 is the most common in the United States, but treatment success rates are higher with genotypes 2 and 3.

Answer 16

seen only in patients with Hep B; acquired in the same ways as Hep B (perinatally, by sexual transmission, contaminated needles, blood transfusions) ## Footnote **IgM antibodies to the Hep D antigen** = resolution of recent infection **(+) Hep D antigen, Hep D virus RNA, and IgM antibodies to Hep D** = chronicity

Answer 17

Hepatitis E is transmitted like hepatitis A (via food and water; no chronic state); often fatal in pregnant women (for unknown reasons).

Answer 18

* **Acetaminophen** * **tuberculosis drugs** (e.g., rifampin, isoniazid, pyrazinamide) * halothane * HMG CoA-reductase inhibitors * carbon tetrachloride first step in treatment is to stop the drug.

Answer 19

Idiopathic autoimmune hepatitis is **classically seen in 20- to 40-year-old women** with **antismooth muscle** or **antinuclear antibodies** and _no_ risk factors or lab markers for other causes of hepatitis. Treat with **steroids**.

Answer 20

Alcohol, hepatitis, and metabolic diseases. Watch for the stigmata of chronic liver disease: * gynecomastia * testicular atrophy * palmar erythema * spider angiomas on skin * ascites

Answer 21

Hepatitis B, C, and D.

Answer 22

Autosomal recessive mutation that results in excessive iron absorption by the intestine and subsequent deposition in the * liver (potentially causing cirrhosis and/or hepatocellular carcinoma) * pancreas (potentially causing diabetes) * heart (resulting in dilated cardiomyopathy) * skin (causing pigmentation classically known as bronze diabetes) * joints (arthritis) Men are symptomatic earlier and more often because women lose iron with menstruation. Treatment: phlebotomy

Answer 23

Autosomal recessive disease resulting in excessive serum copper -\> deposition all over Patients classically have **liver disease** with **CNS/psychiatric manifestations** (caused by copper deposits in the basal ganglia) and **Kayser-Fleischer rings** in the eye. **Serum ceruloplasmin (copper transport protein) = low or absent; serum copper = normal.** Liver biopsy = excessive copper deposition Treat with **penicillamine** (copper chelator).

Answer 24

young adult who develops cirrhosis and/or emphysema without risk factors for either; diagnosis requires a serum A1AT \< 11 μmol/L + genotype

Answer 25

* **Coagulopathy**: Prolonged PT and/or PTT (in severe cases); non-responsive to Vitamin K because it cannot be utilized by the damaged liver * Symptomatic patients must be treated with **fresh frozen plasma.** * **Jaundice/hyperbilirubinemia:** Elevated conjugated and unconjugated bilirubin * **Hypoalbuminemia** * **Ascites**: due to portal HTN +/- hypoalbuminemia; (+) shifting dullness or a positive fluid wave * possible complication: **spontaneous bacterial peritonitis** * ****caused by infected ascitic fluid that can lead to sepsis; culprits: E. coli, Streptococcus pneumoniae, and other enteric bugs * Sx: fever +/- AMS * Dx: paracentesis, examine the ascitic fluid for elevated WBC (especially PMNs), and do Gram stain, culture, and sensitivity tests, as well as glucose (low with infection), and protein (high with infection) tests. * Treat with broad-spectrum antibiotics (**cefotaxime** is a common choice). * **Portal HTN:** causes hemorrhoids, varices, and caput medusae * **Hyperammonemia**: The liver clears ammonia. * Treat with decreased protein intake (source of ammonia) and lactulose (prevents absorption of ammonia). The last choice is neomycin (which is not used as much as it once was), which kills bowel flora that make ammonia. * **Hepatic encephalopathy:** caused by hyperammonemia; often precipitated by protein intake, GI bleed, or infection. Look for asterixis and/or mental status changes. * **Hepatorenal** **syndrome**: Liver failure may cause kidney failure (idiopathic). * **Hypoglycemia**: The liver stores glycogen. * **Disseminated intravascular coagulation**: Activated clotting factors are normally cleared by the liver.

Answer 26

* **Elevated conjugated bilirubin.** Conjugated bilirubin is more elevated than unconjugated bilirubin because the liver still functions and can conjugate bilirubin, but conjugated bilirubin cannot be excreted because of biliary tract disease. * **Markedly elevated alkaline phosphatase** * **Pruritus** * **Clay-colored stools** * **Dark urine,** which is strongly positive for conjugated bilirubin. Unconjugated bilirubin is not excreted in the urine because it is tightly bound to albumin.

Answer 27

* Bile duct obstruction * cholestasis * cholangitis * primary biliary cirrhosis * primary sclerosing cholangitis

Answer 28

**obstruction with a gallstone (choledocholithiasis)** * four Fs (female, forty, fertile, and fat) * detection: US, MRCP, ERCP * trmt: endoscopic removal **malignancy (ie pancreatic cancer, cholangiocarcinoma, bowel cancer)** * weight loss, courvoisier sign (jaundice + palpable gallbladder)

Answer 29

* Medications (e.g., birth control pills, trimethoprim-sulfamethoxazole, phenothiazines, androgens) * pregnancy

Answer 30

* milddle aged women w/o risk factors for liver/biliary disease * marked pruritus * jaundice * positive **antimitochondrial antibodies** treatment: **Cholestyramine** (bile acid sequestrant, which binds bile in the GI tract to prevent its reabsorption) helps with symptoms, but the only treatment is **liver transplantation.**

Answer 31

young adults with inflammatory bowel disease (usually ulcerative colitis) symptoms: fever, chills, pruritus, and RUQ pain

Answer 32

precipitated by a **gallstone** that blocks the common bile duct with subsequent **infection of the bile duct system**. The tip-off is the presence of **Charcot triad**: fever, RUQ pain, and jaundice Treatment: antibiotics + remove gallstones surgically or endoscopically

Answer 33

**Dysphagia** (difficulty in swallowing) and/or **odynophagia** (painful swallowing). Patients may also have atypical chest pain.

Answer 34

incomplete relaxation of the lower esophageal sphincter + loss/derangement of peristalsis; usually idiopathic but may be secondary to **Chagas disease (Reduviid bug)** sx: intermittent dysphagia for solids and liquids, but no heartburn because the lower esophageal sphincter stays tightly closed and does not allow acid to reflux dx: **Barium swallow** reveals a dilated esophagus with distal “bird-beak” narrowing, confirmed with **esophageal manometry** Treatment: **Ca channel blockers**, pneumatic balloon dilatation, or botulism toxin injection. Surgery (myotomy) is a last resort. Risk: **esophageal carcinoma**

Answer 35

diffuse esophageal spasm and nutcracker esophagus (best thought of as a special variant of esophageal spasm) are characterized b**y irregular, forceful**, and **painful** **esophageal contractions** that cause intermittent chest pain. Dx: **esophageal manometry**. Trmt: **calcium channel blockers** and, if needed, **surgery (myotomy)**

Answer 36

Scleroderma causes **esophageal fibrosis + atrophy of smooth muscle;** lower esophageal sphincter becomes incompetent and patients can experience **heartburn** (in contrast to achalasia). Other associated symptoms include: **masklike facies, CREST** (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasias) Dx: (+) ANA

Answer 37

adenocarcinoma is now more common than squamous cell carcinoma. * **Adenocarcinoma** - caused by the long-standing effects of gastric acid reflux and thus occurs in the *_distal_* esophagus. * **Squamous cell carcinoma -** caused by alcohol + tobacco (synergistic effect); classically seen in *black men \> 40 yo who smoke and drink alcohol; (+) weight loss, food “sticking” in the chest;* tumor usually in the *_proximal_* esophagus

Answer 38

Barrett esophagus, usually is caused by longstanding GERD, predisposes to esophageal **adenocarcinoma** pathology: **columnar metaplasia of the normal squamous cell esophageal mucosa** diagnosis & management: **endoscopy** + **endoscopic biopsy, with periodic biopsies to monitor for the development of esophageal cancer**

Answer 39

alcohol or gallstones (most common) Others: hypertriglyceridemia, viruses (mumps, coxsackie virus), trauma, hypercalcemia, PUD, medications (isoniazid, furosemide, simvastatin, steroids, azathioprine), and scorpion stings Acute Signs: epigastric abdominal pain that radiates to the back, nausea with vomiting that fails to relieve the pain, leukocytosis, and elevated amylase/lipase Severe Signs: **Grey Turner sign** (blue-black flanks) and **Cullen sign** (blue-black umbilicus), both of which are because of a *hemorrhagic pancreatic exudate*

Answer 40

Severe signs of pancreatitis: * **Grey Turner sign** (blue-black flanks) * **Cullen sign** (blue-black umbilicus), both of which are because of a *hemorrhagic pancreatic exudate*

Answer 41

NPO + NGT (optional) + IVF + pain meds (hydromorphone or fentanyl)

Answer 42

1. pseudocyst formation (drain surgically if symptomatic and persistent for several weeks) 2. abscess or infection (treat with antibiotics and drainage if needed) 3. chronic pancreatitis

Answer 43

alcoholism note: gallstones do _not_ cause chronic pancreatitis sequelae: * diabetes * steatorrhea * pancreatic calcifications * ADEK deficiencies * increased risk of pancreatic cancer treatment: * alcohol abstinence * PO pancreatic enzyme replacement * fat soluble vitamin supplements

Answer 44

**Mallory-Weiss tears -** superficial erosions in the esophageal mucosa * usually stop bleeding on their own or with endoscopic treatment **Boerhaave tears** - full-thickness esophageal ruptures * require immediate surgical repair and drainage Sx: **GI bleed, vomiting + retching** (alcoholics and bulimic patients) if they are not iatrogenic (endoscopy) Dx: endoscopically (bleeding vessels should be sclerosed) and/or CT with contrast

Answer 45

With suspected GI perforation, do not use barium for contrast studies because it can cause **chemical peritonitis** or **mediastinitis** Alternative: **water-soluble contrast (gastrografin)** with one caveat: can cause chemical pneumonitis in patients with a significant aspiration risk (but oddly, the lungs tolerate barium well)

Answer 46

diaphragmatic hernia - results in bowel herniation into the thorax and causing lung compression, which results in **pulmonary hypoplasia**. sx: respiratory distress with bowel sounds in the chest, bowel loops in the thorax on CXR male left side

Answer 47

**_Omphalocele_** * midline * abdominal organs sealed with intact sac * absent umbilical ring * other anomalies are _common_ **_Gastroschisis_** * located to the right of the midline * only small bowel is exposed (no true hernia sac) * umbilical ring is present * other anomalies are _rare_

Answer 48

**vasculitis** * may present with **GI bleeding + abdominal pain** * history of URIs * characteristic rash on lower extremities and buttocks * swelling in hands and feet * arthritis * hematuria and **proteinuria** Treatment: hydration, rest, and pain relief

Answer 49

viral gastroenteritis (Norwalk virus, rotavirus) should be noted that diarrhea is often a nonspecific sign of any systemic illness (e.g., otitis media, pneumonia, urinary tract infection).

Answer 50

True - diarrhea, fever, bloody stools, anemia, joint pains, and poor growth are more concerning for IBD. GI complaints may be caused by anxiety or psychiatric problems; watch for separation anxiety, children who do not want to go to school, depression, and child abuse.

Answer 51

determine if jaundice is physiologic or pathologic - measure **total, direct, and indirect** bilirubin Concern: kernicterus (caused by high levels of unconjugated bilirubin with subsequent deposit in the basal ganglia); poor feeding, seizures, flaccidity, opisthotonos, and apnea in the setting of severe jaundice. * ^{opisthotonos - spasm of the muscles causing backward arching of the head, neck, and spine, as in severe tetanus}

Answer 52

* occurs because of **incomplete maturation of liver functioning** * 50% of normal infants get experience this, higher incidence in premature infants * **peaks 2 days after birth, resolves in 2 weeks for normal infants** * **peaks 3 days after birth, resolves in 3 weeks for preemies**

Answer 53

**_pathologic jaundice_** - jaundice present at birth or \<24 hours post-partum; may be caused by: * **Breast milk jaundice:** cause peak bilirubin levels at 2-3 wks; temporarily stop breastfeeding until it resolves. * **Illness**: Infection or sepsis, hypothyroidism, liver insult, cystic fibrosis, and other illnesses *may prolong neonatal jaundice and lower the threshold for kernicterus* * **Hemolysis**: From Rhesus (Rh) incompatibility or congenital RBC diseases that cause hemolysis in the neonatal period. Look for anemia, peripheral smear abnormalities, (+) family hx, and *higher levels of unconjugated bilirubin.* * **Metabolic disorders:** * **** Crigler-Najjar cause severe _unconjugated_ hyperbilirubinemia, whereas Gilbert cause a mild form * (both are **C**onju**G**ation problems) * Rotor and Dubin-Johnson cause _conjugated_ hyperbilirubinemia * **Biliary atresia**: Full-term infants with clay- or gray-colored stools and high levels of conjugated bilirubin. Treat with surgery. * **Medications**: Avoid sulfa drugs in neonates; *they displace bilirubin from albumin and may precipitate kernicterus.*

Answer 54

Unconjugated hyperbilirubinemia that persists, rises above 15 mg/dL, or rises rapidly is treated with **phototherapy** to convert unconjugated bilirubin to a water-soluble form that can be excreted. A last resort i**s exchange transfusion**, but should not be implemented unless the level of unconjugated bilirubin is \> 20 mg/dL.

Answer 55

infant should receive **first immunization shot PLUS hepatitis B Ig** at birth

Gastroenterology Flashcards

(92 cards)