likely diagnosis with solid food dysphagia episodially for months or years
esophageal web or schatzki ring
likely diagnosis with progressively increasing solid food dysphagia
peptic stricture or esophageal CA
progression of tests required to dx achalasia
1: barium swallow
2: manometry
3: upper endoscopy (r/o CA)
1st line tx for achalasia
myotomy or dilation
botulinum is second line
meds only if can’t tolerate the above
what do you do if gerd sx don’t respond to PPI
increase to bid for 4-8 weeks (if no alarm sx)
then up[per endoscopy
and if normal correlate sx with amb pH monitoring
when do you tx barrets esophagus
high grade dysplasia (endoscopic tx)
other than PPI of course
frequency of EGD for barrets without dysplasia
q3-5 yrs
q6-12 months if low grade dysplasia
Dx of eosinophilic esophagitis
food impaction/dysphagia/young
EGD with stacked circular rings, mucosal furrowing and friability and white specks
trial 8 weeks PPI to determine if GERD associated or not
tx for eosinophilic esophagitis
PPI if GERD associated
if primary swallowed fluticasone or budesonide
which PUD ulcers need biopsy
any gastric
duodenal only if refractory to therapy (lower risk for CA)
which PUD patients need H. Pylori testing
ALL
approach to patient <50 with dyspepsia without alarm sx
test and tx for h pylori
thing you need to look for prior to gastric emptying study in DM
make sure glucose <275 because hyperglycemia alone can slow gastric emptying
diagnosis and tx for post-gastric bypass
loose stools and cramps 15 min after meals
+ lightheadedness/diaphoresis 90 min after
dumping syndrome
small low carb meals
diagnosis and tx for loose stools and malabsorption post gastric bypass
blind loop syndrome
antibiotics and supplements
test you need to do in a young patient with chronic pancreatitis
CF testing
tests you need to do in older patients with chronic pancreatitis
exclude autoimmune pancreatitis and pancreatic cancer
autoimmune pancreatitis presentation (sx and imaging)
painless obstructive jaundice!
or rarely acute pancreatitis
image shows sausage shaped pancreas
TypeI vs II autoimmune pancreatitis
type I-asosciated with sjogren, psc, ibd in older men, IgG4
type II-chronic pancreatitis without disease associations and with nl igg4
Tx of autoimmune pancreatitis
steroids
food poisoning that happens 6 hrs after eating
staph aureus or b cereus
food poisoning that happens 8-14 hrs after eating
c. perfringens
food poisoning >14 hrs after eating
ehec/viral/etec
whipple disease presentation
arthralgia, fever, neurologic, ocular, cardiac
+ chronic diarrhea
celiac sprue presenation
chronic diarrhea in someone who went to india or puerto rico (obvious combination)
celiac sprue treatment
sulfonamide or tetracycline + folate
what do you do if celiac patient has recurrent symptoms and is confirmed gluten compliant
look for lymphoma (or could be microscopic ibs)
how do you confirm diet compliance in celiac
antittg or small bowel biopsy
tx for mild vs moderate vs severe UC
mild-just start sulfasalazine or mesalamine (timed release mesalamine if small bowel involved!)
moderate-prednisone or budesonide to achieve remission + sulfasala/mesalamine
severe-iv steroids and just start an anti TNF
first and second agents for chron’s maintenance
try 5 asa (mesala/sulfasala) often doesn’t work
then move on to 6mp/azathio/mtx which work better
meds for fistulizing chron’s
azathioprine, 6 mp or especially anti tnf (not mtx)
test required before starting azathioprine or 6 mp
thiopurine methyltransferase levels (some patients lack activity, causes toxicity)
colonosocopy finding after prolonged senna use
benign hyperpigmentation (melanosis coli)
when do you do surgical resection in diverticulitis
complicated of course but more importantly
after second episode (50% risk of recurrence at that point)
tx of acute mesenteric ischemia without peritonitis and with non-occlusive disaease
intra-arterial papaverine
normal conjugated/unconjugated ratio
normally-80% unconjugated
what do you need to test for in suspected gilberts
confirm ast/alt oare ok, confirm no hemolysis (nl cbc/retic)
who gets hep A immunoglobulin
close contacts, people who ate infected food, or traveling within 2 weeks to endemic areas
post-exposure prophylaxis for hep b
immune globulin + vaccine
who gets hep b tx
acute liver failure
chronic with elevated ALT AND HBV DNA >10,000
immunosuppressive tx
how do you treat hep b (which meds)
entecavir or tenofovir
what do you need to monitor with interferon alpha tx
thyroid levels (hypothyroid common
who gets HCC monitoring with chronic hep b
cirrhosis
>20,000 DNA, and elevated ALT
asian (>40-50 yo)
black (>20 yo)
which HCV patients get HCC monitoring
cirrhosis, q6 mo
score cut offs for steroids in alcoholic hepatitis
maddrey >32, meld >18, or just encephalopathy and ascites
stop if bili not better by day 7
when should you avoid steroids in alcoholic hepatitis
avoid if kidney disease, gi bleed, pancreatitis or infection
alcoholic hepatitis antibodies
anti sm musc ana pANCA anti LKM 1 \+ elevated igG (i.e. low albumin, high protein)
main demographic of alcoholic hepatitis
women 20-40 yo
characteristic arthritis in hemochromatosis
second and third mcps with hook like osteophites, OA in weird joints like ankle, shoulder, elbow
differentiate advanced liver disease vs hemochromatosis on iron studies
advanced liver disease increases ferritin, but usually maintains nl percent sat (i.e. <55%)
classic triad in PBC
cholestasis
anti mito antibody
granulomatous inflammation on septal bile duct
(women 40-60)
complications of PBC
fat soluble vitamin deficiencies and osteoporosis/malacia
tx for PBC
ursodeoxycholic acid
Bile duct pathology in PBC vs PSC
PBC: small bile ducts
PSC: large bile ducts
demographics of PBC vs PSC
PBC: women 40-60, various autoimmune diseases coexist
PSC: men 20-30, IBD
“string of beads” on MRCP/ERCP diagnosis
PSC
positive anti mitochondrial ab disease
PBC
tx for PSC
tx strictures endoscopically and liver txpl (cholestyramine for itching)
use ascitic protein to differentiate etiology of high saag ascites
<2.5-cirrhosis
>2.5-HF or budd chiari
use ascitic protein to differentiate etiology of low saag ascites
<2.5-nephrotic syndrome
>2.5-malignancy or TB
test to confirm hepatopulmonary syndrome
agitated saline enhanced echo
what osteoporosis tx is appropriate in cirrhosis
only IV if they have esophageal varices
differentiate AFLP from HELLP
encephalopathy or hypoglycemia suggest AFLP
hellp has more TMA
AFLP has more coag problems
(who cares, schedule delivery)
tx for wilson disease
chelation with penicillamine or trientine
tx for amanita mushroom poisoning
penicillin g or silymarin
tx for biliary colic
nsaids decrease risk of progression to cholecystitis
what is mirizzi syndrome
gall stone is in cystic duct (so cholecystitis), stone extrinsically compresses cbd so cbd is NOT dilated but liver enzymes are elevated
findings on egd suggesting low risk ulcer
clean base or nonprotruberant pigmented spot
timeline to endoscopy in UGIB
w/in 24 hrs or 12 hrs if expect varices
likely source of gib in young patient with painless hematochezia and nl egd/colo
meckel diverticulum
first step for recurrent gib without identified source after egd/colo
repeat egd colo (diagnostic 40% of the time)
recommended next steps for active obscure gib
apparently tagged scan first then cta
then consider push enteroscopy
then surgery