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Gastroenterology Flashcards

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1
Q

Which anatomical structures are evaluated by the following radiologic studies?

  • Barium swallow
  • Gastric emptying study
  • Small bowel follow through
  • Barium enema
A
  • Barium swallow
    • esophagus, LES, stomach
  • Gastric emptying study
    • Stomach, pyloric valve, duodenum
  • Small bowel follow through
    • Stomach to terminal ileum
  • Barium enema
    • Rectum to appendix.
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2
Q

Achalasia

A
  • Impaired peristalsis and decreased LES relaxation because of intramural neuron dysfunction.
  • Pt
    • progressive dysphagia of solid + liquids.
    • regurgitaiton, weight loss, aspiration, heartburn.
  • Dx
    • manometry has increased LES pressure w/ incomplete relaxation and poor peristalsis.
  • Tx
    • dilation + myotomy = high risk for perforation
    • botulinum toxin = pt who is poor surgical candidate.
    • nitrates/ dihydropyridine CCB

**must perform EGD w/ Bx to rule out malignancy**

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3
Q

Red Flag signs for GERD

A
  • Red Flag signs/symptoms
    • bleeding, weight loss, dysphagia, odynophagia, protracted vomiting.
  • In these cases consider performing endoscopy
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4
Q

Esophageal Cancer

A
  • Types
    • squamous cell carcinoma (alcohol and smoking. Typically upper 1/3)
    • adenocarcinoma (obesity, Barrett’s. Typically lower 1/3)
  • Pt
    • progressive dysphagia, weight loss, GI bleed, vomiting, weakness, cough, hoarseness.
  • Dx
    • barium swallow (esopahgealnarrowing and mass)
    • EGD is test of choice. ALlows for Bx of tissue.
  • Tx
    • esophagectomy for early disease
    • radiation +/- chemotherapy if later stage.
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5
Q

Gastritis

A
  • Causes
    • H.pylori, chronic NSAID, alcohol, msoking, autoimmune disease.
  • Pt
    • epigastric pain, nausea, vomiting, loss of appetite, early satiety, weight loss
  • Dx
    • EGD w/ Bx.
    • H.pylori (urea breath test) antral biopsy, serum antibodies.
  • Tx
    • stop offending medication
    • H.pylori (-): PPI, H2 blocker.
    • H.pylori (+): PPI, amoxicillin, clarithromycin. Metronidazole if PCN allergy.
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6
Q

Common causes of Upper GI bleeds

A
  1. Peptic ulcer
  2. Esophagitis
  3. Esophageal varices.
  4. Mallory weiss tears
  5. gastritis
  6. gastric/duodenal cancer.
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7
Q

Common causes of Lower GI Bleeds

A
  • Arteriovenous malformation
  • Mesenteric ischemia
  • Meckel’s diverticulum
  • Diverticulosis/-itis
  • Hemorrhoids
  • Ulcerative colitis
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8
Q

Management of Upper GI bleed

A
  1. ABC’s
  2. admit to ICU- npo
  3. type and screen 2 units PRBC.
    1. transfuse if Hgb < 7.0
  4. Labs
    1. CBC, PT, INR, BUN, Cr.
  5. NG lavage or EGD if uncertain of GI bleed location
  6. Meds
    1. IV PPI (omeprazole)
    2. variceal: octreotide

Once stabilized can perform EGD.

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9
Q

What are steps in managing lower GI bleed?

A
  1. Verify hemodynamic stability
    1. type and screen 2 units PRBC.
  2. Labs
    1. CBC, PT, PTT, BUN, Cr.
  3. EGD as needed
  4. Colonoscopy (if hemodynamically stable and not actively bleeding)
    1. if unable:
      1. angiography
      2. radionuclide scan (tagged RBC scan)
      3. capsule endoscopy

** the last 1-3 would only be used if there is still slow active bleed**

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10
Q

Whipple Disease

A
  • Malabsorption d/t Tropheryma whipplei.
  • Pt
    • abd pain, diarrhea, weight loss, joint pain, neurological changes.
  • Dx
    • intestinal biopsy w/ blunting villi
    • PAS (+).
  • Tx
    • IV ceftriaxone, 9-12mon Bactrim.

PAS(+), intestinal villi blunting. these alone should differentiate from celiac. Celiac does not contain PAS(+), nor does it include neurological deficits.

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11
Q

Tropical Sprue

A
  • Tropica environment
  • Pt
    • steatorrhea, diarrhea, megaloblastic anemia, abd distention, pedal edema.
  • Dx
    • blunting villi.
    • Inflammatory cells in lamina propria.
  • Tx
    • tetracycline
    • folic acid.

Tropics, steatorrhea, MCV > 100 = tropical sprue.

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12
Q

Celiac disease

A
  • Gluten (gliaden) sensitivity
  • Pt
    • Northern European ancestry
    • Bulky, foul smelling diarrhea. Steatorrhea.
    • weight loss.
    • Iron deficient anemia, Osteopenia. dermatitis herpetiformis
  • Dx
    • anti-IgA-transflutaminase antibodies. anti-endomysial ab (+)
    • Bx: blunting villi w/ hypertrophic crypts.
  • Tx
    • gluten free diet.
    • dermatitis treat w/ Dapsone.
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13
Q

Stool osmotic gap

A

Gap = 290 - 2 (Na + K) (50-100 Normal)

  • Gap >125 = osmotic
    • lactulose.
    • celiac, whipple disease
    • pancreatic insufficiency.
  • Gap < 50 = secretory
    • Carcinoid syndrome.
    • VIPoma, gastrinoma.
    • Cholera
    • ETEC
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14
Q

Most likely diagnosis for each of the following:

  • Chronic diarrhea + itchy grouped vesicles on elbows and knees
  • Recent immigrant from Dominican Republic w/ foul-smelling chronic diarrhea + macrocytic anemia.
  • Caucasian w/ foul chronic diarrhea + iron deficiency anemia
  • Chronic diarrhea + arhtralgias + ataxia
A
  • Chronic diarrhea + itchy grouped vesicles on elbows and knees
    • Celiac disease
  • Recent immigrant from Dominican Republic w/ foul-smelling chronic diarrhea + macrocytic anemia.
    • Tropical sprue
  • Caucasian w/ foul chronic diarrhea + iron deficiency anemia
    • Celiac disease
  • Chronic diarrhea + arhtralgias + ataxia
    • Whipple disease
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15
Q

Bacillus Cereus

A

Bacterial Gastroenteritis

  • Source:
    • refried Rice
  • Pt
    • self limited diarrhea.
  • Tx
    • Hydration
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16
Q

Campylobacter jejuni

A

Bacterial Gastroenteritis

  • Source:
    • poultry
  • Pt
    • mostly watery diarrhea. +/- blood.
    • second most common foodborne bacterial GI infection.
  • Tx
    • Hydration, fluoroquinolone or azithromycin

**Risk of guillain-barre syndrome and reactive arthritis (can’t see, can’t pee, can’t climb tree) conjunctivitis, urethritis, arthritis**

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17
Q

Clostridium botulinum

A

Bacterial Gastroenteritis

  • Source:
    • Honey (infants < 12mo) organism enters and locates into GI tract.
    • Home-canned goods - ingestion of preformed toxin
  • Pt
    • NVD, bilateral symmetric descending weakness starting at head.
  • Tx
    • monitor. Intubate if needed.
    • Botulinum antitoxin w/ Penicillin G
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18
Q

Clostridium difficile

A

Bacterial Gastroenteritis

  • Source:
    • Superinfection s/p antibiotics; clindamycin
  • Pt
    • watery or bloody diarrhea.
    • Pseudomembranous colitis formation (grey mucous formation)
  • Tx
    • Metronidazole (unless alcoholic Hx/abuse)
    • PO vancomycin (1st line in clinic. unsure for test)
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19
Q

Enterotoxigenic E.coli (ETEC)

A

Bacterial Gastroenteritis

  • Source:
    • contaminated food/water
  • Pt
    • self-limited watery diarrhea
  • Tx
    • hydration.
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20
Q

Enterohemorrhagic E.coli(EHEC)

A

Bacterial Gastroenteritis

  • Source:
    • undercooked ground beef
    • E.coliO157:H7
  • Pt
    • bloody diarrhea, vomiting, abd pain.
  • Tx
    • hydration, support. (no antibiotics as this will increase toxin release and worse disease)

Association: HUS (children) - thrombocytopenia, hemolytic anemia, acute renal failure.

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21
Q

Staphylococcus aureus

A

Bacterial Gastroenteritis

  • Source:
    • poultry, egg, dairy at room temperature.
  • Pt
    • rapid onset of GI upset, diarrhea.
    • onset within 2-6 hours of ingestion
  • Tx
    • hydration. self limited
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22
Q

Salmonella spp

A

Bacterial Gastroenteritis

  • Source:
    • raw meat, poultry, fresh produce.
    • most common foodborne GI infection
  • Pt
    • bloody diarrhea, fever, vomiting
  • Tx
    • hydration
    • fluoroquinolones
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23
Q

Shigella

A

Bacterial Gastroenteritis

  • Source:
    • food and water ingestion
  • Pt
    • fever, nausea, vomiting, severe bloody diarrhea, abd pain, HUS (hemolytic anemia, thrombocytopenia, acute renal failure)
  • Tx
    • hydration
    • fluoroquinolone
    • bactrim(TMP-SMX)
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24
Q

Vibrio cholerae

A

Bacterial Gastroenteritis

  • Source:
    • seafood ingestion
  • Pt
    • rice-water diarrhea
    • electrolyte imbalance, death
  • Tx
    • aggressive hydration. Tetracycline, doxycycline.
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25
Yersinia enterocolitica
Bacterial Gastroenteritis * Source: * pork, puppy feces. * Pt * diarrhea, pharyngitis, **pseudoappendicitis** * Tx * hydration replacement.
26
Giardia lamblia
Parasitic/Protozoal Gastroenteritis * Source: * Mountain water * Pt * greasy, foul smelling diarrhea. * Malaise. * Tx * Metronidazole. Dx: cysts + trophozoites in the stool.
27
Entamoeba histolytica
Parasitic/Protozoal Gastroenteritis * Source: * streams * Pt * bloody diarrhea. Abd pain. * Tx * Metronidazole (1st) * Paramomycin (2nd) Severe cases risk progression into liver abscess ( RUQ pain, liver abscess, diarrhea)
28
Cryptosporidium parvum
Parasitic/Protozoal Gastroenteritis * Source: * food or water * Pt * Immunocompromised. * watery diarrhea, abd pain, malaise. * Tx * Nitazoxanide Dx: Acid fast stain (+) for parasite.
29
Trichinella spiralis
Parasitic/Protozoal Gastroenteritis * Source: * undercooked pork * Pt * fever, myalgias, periorbital edema, eosinophilia, CNS changes, cardiac symptoms * Tx * albendazole, mebendazole.
30
Taenia solium
Parasitic/Protozoal Gastroenteritis * Source: * undercooked pork * Pt * diarrhea, CNS symptoms * Tx * Praziquantel = gut infection * Albendazole = CNS symptoms. Taeniasis = tapeworm in gut only Cysticercosis = cyst in muscles Neurocysticercosis = brain cysts.
31
Most common foodborne bacterial GI infections in US
* Campylobacter jejuni * Shigella.
32
Cholelithiasis
* Pt * postprandial RUQ pain worse after fatty meal. * NV, abd fullness. * Dx * normal labs * RUQ ultrasounds shows hyperlucent gallstones. * Tx * Cholecystectomy * risk progression to acute cholangitis, acute pancreatitis.
33
Charcot's triad
* Jaundice * Fever * RUQ pain Strong indicator for acute cholangitis
34
Reynold's pentad
* Fever * jaundice * RUQ pain * AMS * HoTN
35
Treatment for acute cholangitis
* Broad spectrum Abx * piperacillin-tazobactam, levofloxacin * Endoscopic biliary drainage * Delayed cholecystectomy
36
Porcelain Gallbladder
* Strong indicator for progression to Gallbladder adenocarcinoma (90%). * Pt * asymptomatic * abd pain, jaundice, weight loss, vomiting. * palpable gallbladder. * Dx * high bili and alk phos * porcelain gallbladder - thickened wall w/ circumferential wall calcification. * Tx * **Cholecystectom+ LN dissection + local hepatic resection.** * **+/- post op chemo or radiation.**
37
Which patients are at high risk of acalculous cholecystitis?
Severely ill TPN-patient.
38
What is medical management for ulcerative colitis?
* Mesalamine - small bowel * Sulfasalazine - large bowel steroids as adjuvants during acute flare.
39
Which bacterial GI infection is most likely associated with diarrhea and pseudoappendicitis?
*yersinia enterocolitica.*
40
Primary biliary cholangitis
* Female predominant *autoimmune destruction of **Intrahepatic bile duct*** leading to cirrhosis. * Pt * fatigue, pruritus. Hyperpigmentation, xerosis. Xanthoma, Xanthelasma, Hepatomegaly, Malabsorption, steatorrhea, cirrhosis, jaundice, edema, portal HTN. * DX * high alk phos, high bili, high cholesterol * (+) AMA-ab * (+) ANA * TX * ursodeoxycholic acid. * liver transplant.
41
Primary sclerosing cholangitis
* Progression inflammation and fibrosis and sclerosis of **intrahepatic/extrahepatic** bile ducts. * Pt * Men ≥ 40yo. **Assoc w/ ulcerative colitis.** * DX * (+) p-ANCA. * ERCP shows "beads on a string" * Tx * no effective pharmacotherapy. * liver transplant.
42
Crigler-Najjar type I
* Severe UDPGT deficiency. * PT * persistent neonatal jaundice and kernicterus * Lab * indirect bili \> 5mg/dL * Tx 1. Phototherapy 2. Plasmapheresis 3. Liver transplant.
43
Crigler-Najjar Type II
* Mild UDPGT deficiency * Pt * jaundice starting in childhood or adolescence * Labs * Mildly elevated indirect bili * Tx * Phenobarbital
44
Hepatitis A
* Fecal-oral transmission. Typically on international travel. * Labs * Hep A IgM-ab during illness * Hep A IgG-ab after resolution or vaccine. * Tx * supportive * vaccine is available.
45
Hepatitis E
* Fecal-oral transmission. * Most often seen in pregnant women, causing fulminant hepatic failure. * Labs * PCR, Hep E IgM-ab. * Tx * supportive
46
Hepatitis B
* Perinatal + sexual contact transmission * 90% or virus is acquired via perinatal transmission. * Pt * polyarteritis nodosa, nephropathy, aplastic anemia. * High risk of Hepatocellular carcinoma (elevated AFP)
47
Hep B surface antigen (HBsAg)
indicates active disease
48
Hep B surface antibody (HBsAb)
indicates recovery from active infection or immunization
49
Hep B core antibody (HBcAb)
History of infection. (IgM early, IgG late)
50
Hep B envelope antigen (HBeAg)
active viral replication ## Footnote **High transmissibility**
51
Hep B envelope antibody (HBeAb)
Low transmissibility
52
Hep B DNA (HB DNA)
active viral replication; treatment is indicated when values are high.
53
Treatment for HBV
Tenofovir, entecavir, telbivudine, lamivudine, adefovir. Pregnant: lamivudine if viral count is high. Baby receives Hep B vaccine and Hep B immune globulin within 12 hours of birth.
54
Hepatitis D
* Only able to infect in presence of HBV * blood and sexual contact transmission * Carries highest mortality rate * Tx * pegylated IFN-alpha. * prophylaxis w/ HBV vaccine.
55
Which virus carries the highest risk of hepatocellular carcinoma?
HCV \>\>\> HBV
56
Hepatocyte failure results in what?
* elevated bilirubin --\> jaundice * reduced coagulation factors --\> elevated PT, PTT * reduced albumin --\> peripheral edema + ascites * reduced ammonia metabolism --\> hepatic encephalopathy and asterixis * Tx: lactulose (1st), Rifaximin (2nd) * impaired hormone synthesis * testicular atrophy * gynecomastia * spider telangiectasia * palmar erythema
57
What vaccines should be given to patients w/ cirrhosis?
* Hep A * Hep B * Pneumococcal vaccine * other standard immunizations.
58
Causes of Acute pancreatitis?
**PANCREATITIS** * **P**- hyperparathyroidism. * **A**- alcohol (chronic) * **N**- neoplasms * **C**- cholelithiasis * **R**- drugs (NRTI, ritonavir, sulfonamides) * **E**- ERCP * **A**- abd surgery * **T**- hyperTriglyceridemia * **I**- Idiopathic * **T**- trauma * **I**- infection (mumps) * **S**- scorpion sting.
59
What medications are used to treat ileus?
1. Erythromycin 2. Neostigmine 3. Metoclopromide
60
Budd-Chiari * Definition * Presentation
* Thrombosis and occlusion of the hepatic vein or the intrahepatic/suprahepatic portion of inferior vena cava. * Pt * ascites * hepatomegaly * jaundice * RUQ pain, hepatomegaly and jaundice/ascites. * Chronic - gradual ascites, LE edema, cirrhosis and portal HTN over months.
61
Budd- Chiari * Diagnostic technique * Treatment
1. Dx 1. Abd US 2. Hepatic venography 2. Tx 1. thrombolytics 2. diuretics + anticoagulation 3. angioplasty 4. shunt Start with least invasive procedure and progress up until resolution.
62
Explain the SAAG
Serum albumin-ascites gradient. * SAAG \> 1.1 indicates portal HTN (transudative process) * cirrhosis, alcoholic hepatitis, HF, massive hepatic metastases, Budd-Chiari * SAAG \< 1.1 *indicates exudative process* * *peritoneal carcinoma, peritoneal tuberculosis, pancreatitis, serositis.* * Low albumin overall indicates form of nephrotic syndrome.
63
Spontaneous bacterial peritonitis (SBP) * Definition * Presentation
* Infection of ascitic fluid without surgical treatable intra-abdominal source. * Pt * fever, abd pain/tenderness * AMS * Diarrhea - secondary to bacterial overgrowth (most likely E.coli)
64
Spontaneous Bacterial Peritonitis (SBP) * Diagnosis * Treatment
* Dx * SAAG \> 1.1 * Ascites gram stain + Cx * **Ascites neutrophil count \> 250cell/mm.** * low ascites glucose. * Tx 1. Cefotaxime 2. Ceftriaxone 1. treat for 5 days. Allows coverage of gut bacteria 3. Albumin transfusion; maintains plasma volume, reserves renal function and reduces renal impairment/mortality.
65
Common treatment for ascites
Daily **Spironolactone + Furosemide** reduces fluid retention
66
Treatment for Esophageal Varices
* Prophylaxis * Nonselective Bblocker(*propranolol, nadolol)* * Bleeding varices * Octreotide; reduce splanchnic flow * Endoscopic variceal ligation * Endoscopic sclerotherapy. * **Transjugular intrahepatic portosystemic shunt (TIPS)** * creates channel through the liver to shunt blood from **portal to systemic system**. * Has higher risk of hepatic encephalopathy; as ammonia is now not being removed as readily.
67
Hereditary Hemochromatosis * Definition * Presentation
* Autosomal recessive excess iron absorption leading to deposition within tissue. * Pt * Hepatomegaly, abd pain, cirrhosis * Diabetes (insulin resistance) * skin hyperpigmentation * hypogonadism (testicular atrophy) * restrictive cardiomyopathy. * arthralgia
68
Hereditary Hemochromatosis * Diagnosis * Tx
* Dx * High AST, ALT * High iron, high ferritin, high transferrin * Liver Bx show iron granules in hepatocytes. * Tx * Phlebotomy weekly until levels normalize, then monthly. * iron chelation w/ **deferoxamine** * avoid alcohol.
69
Wilson Disease * Define * Pt * Dx * Tx
Autosomal recessive impaired copper secretion leads to deposition in tissues. * Pt * 12-23yo. * Hepatomegaly, hepatic steatosis, cirrhosis. * Dystonia, tremor, parkinsonism * depression, psychosis. * Kayser-Fleischer rings. * Dx * Low Ceruloplasmin * High urinary Copper. * Tx * Copper chelation w/ **trientine, penicillamine** * zinc supplement * restrict dietary copper.
70
Autoimmune hepatitis Define Pt Dx Tx
Autoimmune inflammation of liver * Pt * F\>\>\>M * acute liver failure/cirrhosis * Dx * (+) ANA and anti-smooth muscle Ab * (+) ab against the liver-kidney microsomal Ag. * Tx * glucocorticoids * +/- azathioprine.
71
Hepatic Adenoma Risk Factors Pt Management
Benign liver neoplasm, mostly **F 20-40 on OCP** * Risk Factor * OCP * anabolic steroid use * *glycogen storage disease I/ III* * Pt * asymptomatic * RUQ pain, fullness. * Management * discontinue OCP * monitor w/ imaging and serial AFP
72
Hepatocellular carcinoma Risk Factors Presentation Associated syndromes
* Most common primary tumor of liver. * Risk Factors * HBV, HCV, Cirrhosis, Aflatoxin (aspergillus) * Assoc Syndromes * polycythemia * Hypercalcemia (excess PTH secretion) * Watery diarrhea (VIPoma) * hypoglycemia
73
Hepatocellular carcinoma Dx Tx
* Dx * High LFT * High AFP * **US**- solid tumor follow up with CT/MRI * Tx * Small - surgical resection w/ chemotherapy * Large - liver transplant, radiofrequency ablation, chemoembolization
74
What malignancies have increase EPO production and can likely lead to Polycythemia Vera?
Pheochromocytoma Renal cell carcinoma Hepatocellular carcinoma Hemangioblastoma

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