Gastroenterology

Question 1

Who should be screened for Barrett’s esophagus?

Answer 1

Men with 5+ years of GERD and 2+ risk factors (age>50, white, obese, smoker, FHx BE/esophageal Ca).

Question 2

What method of endoscopic ablation is indicated for low grade non-nodular Barrett’s esophagus?

Answer 2

Radiofrequency ablation.

Question 3

Name 3 surgical and 3 non-surgical treatments for achalasia.

Answer 3

Surgical: pneumatic dilatation, myotomy (e.g. POEMS), esophagectomy.
Medical: botulinum toxin, nitrates, calcium channel blockers.

Question 4

What clinical features suggest eosinophilic esophagitis?

Answer 4

Young male with atopy and solid food dysphagia +/- food boluses.

Question 5

How do you treat eosinophilic esophagitis?

Answer 5

Dietary elimination (eggs, soy, cow’s milk, wheat, tree nuts, seafood), topical steroids with water rinse.

Question 6

How do you work someone up for celiac disease if they are IgA deficient?

Answer 6

Anti-gliadin (DGP) antibody and anti-TTG IgG, if positive then duodenal biopsy.

Question 7

What features suggest severe ulcerative colitis?

Answer 7

> 6 movements per day, urgency, frequent blood, anemia, ESR>30, elevated CRP and fecal calprotectin.

Question 8

What are maintenance options for moderate to severe ulcerative colitis?

Answer 8

Azathioprine, anti-TNFs, tofacitinib (JAK2 inhibitor), vedolizumab (Entyvio, anti-integrin)

Question 9

How do you diagnose toxic megacolon?

Answer 9

1. Colon > 6cm AND
2. 3+ fever, HR>120, anemia, neutrophils >10.5 AND
3. 1+ of dehydration, electrolyte abnormalities, hypotension, altered LOC.

Question 10

Which therapies are not indicated for Crohn’s?

Answer 10

5-ASA (but can use sulfasalazine) and tofacitinib.

Question 11

What are induction options for Crohn’s disease?

Answer 11

IV steroids, methotrexate, anti-TNFs.

Question 12

How do you treat strictures in Crohn’s disease?

Answer 12

Cold stricture: conservative (NGT, IV fluids, pain management), dilatation or surgery.
Hot stricture (mesenteric adenopathy, fat stranding, elevated inflammatory markers): steroid bridge to anti-TNF.

Question 13

Describe Type 1/pauciarticular IBD arthritis.

Answer 13

More common than type 2, <5 joints affected, usually large joints, flare lasts <10 weeks, flare parallels IBD activity.

Question 14

Who gets 72 hours IV PPI post-endoscopy?

Answer 14

Bleeding vessels, visible vessels, non-removable adherent clot.

Question 15

Who should get indefinite PPI therapy after a non-variceal bleed?

Answer 15

On ASA for secondary prevention, on anticoagulation, unclear etiology of peptic ulcer disease.

Question 16

Who should you screen for H. pylori?

Answer 16

PUD, MALT lymphoma, gastric cancer, long term ASA or NSAID use, unexplained iron deficiency, ITP.

Question 17

What are two first line therapies for H. pylori infection?

Answer 17

PBMT or PAMC for 14 days.

Question 18

What is the window period in hepatitis B?

Answer 18

Viral is clearing and HBsAg is negative, but HBsAb has not become positive yet.

Question 19

Which chronic Hep B patients get HCC screening with U/S every 6 months?

Answer 19

1. Asian men, HIV+, family Hx HCC > 40 years.
2. Asian women > 50 years.
3. Black patients > 20 years.
4. All cirrhotics.

Question 20

If HBeAg is negative, what is the HBV DNA cut-off for starting treatment?

Answer 20

> 2000 IU/mL (>20,000 if HBeAg positive).

Question 21

What are two first line treatments for hepatitis B and how long do you treat for?

Answer 21

Tenofovir and entecavir. Treat for life usually.

Question 22

List three extrahepatic manifestations of hepatitis B.

Answer 22

Aplastic anemia, membranous nephropathy, polyarteritis nodosum.

Question 23

What are four disease-specific risk factors for hepatitis B becoming either cirrhosis or hepatocellular carcinoma?

Answer 23

1. High liver enzymes.
2. Prolonged time to eAg seroconversion
3. eAg negative mutant.
4. Genotype C.

Question 24

What metric is used to determine hepatitis C cure?

Answer 24

SVR12 = sustained viral response at 12 weeks after completing therapy.

Question 25

Name two direct-acting antivirals used for hepatitis C.

Answer 25

Epclusa and Maviret.

Question 26

Name 4 autoimmune and 4 hematologic extrahepatic manifestations of hepatitis C.

Answer 26

Autoimmune: diabetes, myastenia gravis, sjogren's, thyroid disease. Hematologic: hemolytic anemia, cryoglobulinemia, lymphoma, ITP.

Question 27

What are the Maddrey discriminant function and Lille score cut-offs in treating alcoholic hepatitis?

Answer 27

If Maddrey score >32 - start prednisolone 40 mg po daily x 28 days. If Lille score <0.45 on day 7 then continue therapy, otherwise stop (Lille low = lucky).

Question 28

Name 3 interventions for treatment of NAFLD/NASH.

Answer 28

1. Lose 3-5% body weight, may require bariatric surgery. 2. Pioglitazone and vitamin E in NASH only. 3. Aggressive cardiovascular risk reduction.

Question 29

What MELD score should be referred for liver transplant?

Answer 29

MELD>15

Question 30

What three screening tests should be performed upon diagnosis of cirrhosis?

Answer 30

Endoscopy for varices, U/S for HCC, paracentesis if ascites) for SBP.

Question 31

Who gets non-selective beta blocker therapy for varices?

Answer 31

Primary prophylaxis: small varices that are high risk (Child Pugh C, red wale, red spot), medium to large varices (can do EVL instead). Secondary prophylaxis: along with EVL.

Question 32

What causes SAAG>11?

Answer 32

Portal hypertension: cirrhosis, liver mets, portal vein thrombosis.

Question 33

What are two contraindications to TIPS?

Answer 33

Hepatocellular carcinoma, encephalopathy.

Question 34

How do you diagnose spontaneous bacterial peritonitis?

Answer 34

Ascitic neutrophils>250 OR positive culture and no other secondary causes.

Question 35

Who gets SBP prophylaxis?

Answer 35

1. Prior SBP. 2. Cirrhosis with variceal bleed. 3. Ascitic albumin < 15 and either renal (Cr>106, BUN>8.9, Na<130) or liver (bili>51 AND Child-Pugh>9) impairment.

Question 36

What are the two types of autoimmune pancreatitis?

Answer 36

Type 1: IgG4-mediated (older men, sausage-shaped pancreas, biliary strictures, other IgG4 organs involved). Type 2: isolated pancreatic disease, associations with IBD.

Question 37

Who do you screen for hereditary hemochromatosis?

Answer 37

First degree relatives of a diagnosed HH case (homozygous at C282Y).

Question 38

What are the phlebotomy targets for hemochromatosis treatment?

Answer 38

Ferritin < 100 in men and < 50 in women.

Question 39

How do you diagnose primary biliary cholangitis?

Answer 39

PBC - middle aged woman with jaundice, pruritis, fatigue. | Diagnose with 2+ of ALP elevated >6 months, AMA>1:40, liver biopsy.

Question 40

How do you diagnose hepatorenal syndrome?

Answer 40

Patients with chronic liver disease with: - Rising Cr and oliguria - Bland sediment and proteinuria <0.5 g/d - Urine sodium < 20 - Ruled out ATN, nephrotoxins, obstruction - No response to stopping diuretics and trialling albumin for 2d

Question 41

What are complications of PPI?

Answer 41

``` C diff, pneumonia HypoMg, Low B12 AIN/CKD Dementia Low BMD Gastric Ca ```

Question 42

What is the management of indefinite esophageal dysplagia on OGD for Barrett's?

Answer 42

Optimize PPI, then EGD. If still indefinite, repeat bx in 1 year If histology changed, manage per new histology

Question 43

When and how long do you do SBP prophylaxis in UGIB?

Answer 43

Both non variceal and variceal bleed in setting of cirrhosis. Ceftriaxone 1g Q24h x up to 7 days or till when octreotide stops

Question 44

Who should you screen for Hep C?

Answer 44

Risk factor based screening: IVDU/incarceration/sexual contact/HIV/MSM Healthcare worker Transfusion prior to 1992 Born to mother with Hep C or endemic areas

Question 45

How do you manage scope-proven esophagitis?

Answer 45

PPI and lifestyle changes, monitor lifestyle changes, increase to BID if refractory, switch PPI if refractory past 8 weeks.

Question 46

What are the findings of hemochromatosis:

Answer 46

Tan, arthralgias, chondrocalcinosis of 2nd and 3rd MCP, neuropathy, cardiomyopathy, diabetes, hypopituitarism, hypogonadism