Flashcards in Gastroenterology Deck (93):
What is the differential for an elevated AFP (3)?
1. Hepatocellular carcinoma
3. Germ Cell Tumors
Which chronic disease and what malignancy is associated with Primary Sclerosing Cholangitis?
1. Ulcerative Colitis (80% of PSC)
2. Cholangiocarcinoma (10%)
1. Name two chronic diseases ASSOCIATED with Celiac Disease.
2. Name two malignancies associated with Celiac Disease.
1. DM1 and autoimmune thyroditis
2. Enteropathy-associated T-cell lymphoma AND Non-Hodgkin lymphoma
What serologic labs can be checked for Celiac Disease (4)? Which are more sensitive and specific?
1. Anti-tissue transglutaminase IgA ab*
2. Anti-endomysial IgA ab*
3. Anti-tissue transglutaminase IgG ab assays**
4. Antigliadin antibody***
*High sensitivity and specificity
**Low sensitivity and high specificity but some have IgA deficiency, thus measure IgG antibody
***Not useful in diagnosis, however useful in following dietary response to gluten withdrawal
1. What is waterbrash? What does it suggest?
2. What is rumination?
1. Salty food taste in mouth - from GERD
2. Effortless regurgitation into mouth
What scenarios would warrant EGD evaluation for GERD (4)?
1. Fail to respond to treatment
2. Symptoms greater than 5 years
3. Older than 50yo
4. Alarm symptoms: weight loss, dysphagia, anemia
1. There is a long-term anatomical complication from GERD. How would anti-reflux surgery affect this complication?
2. What is a nonsurgical option for patients with Barrett's high grade dysplasia who do not want esophagectomy?
3. What is a complication?
1. It does NOT alter natural history of Barrett's
2. Endoscopic ablation
3. Esophageal strictures
For Gastric Squamous Carcinoma vs. Adenocarcinoma:
1. Which races are more affected?
2. What are risk factors?
3. Where do they arise?
3. Adenocarcinoma: Distal
Squamous Cell: Mid-esophagus
1. What is the test of choice for Achalasia and how does it appear?
2. What are treatment options (4)?
1. Barium esophagography --> air-fluid level with "bird's beak" appearance
2. a. Heller myotomy (+ Nissen) - durable
b. Pneumatic dilation
c. Botox - short-term 12 months
d. CCB - last line therapy
1. What is the difference between Diffuse Esophageal Spasm and Nutcracker Esophagus?
2. How are they diagnosed?
Diffuse Esophageal Spasm - simultaneous esophageal contractions interspersed with normal peristalsis
Nutcracker Esophagus - Very high amplitude peristaltic contractions
**Diagnosed by Esophageal Manometry
1. What is the treatment for Candida esophagitis?
2. What is the treatment for CMV esophagitis (3)?
3. What is the treatment for HSV esophagitis?
1. Fluconazole or Itraconazole
2. Ganciclovir, Foscarnet, Cidofovir or Acyclovir
3. Famciclovir or Acyclovir --> Foscarnet
What drugs are implicated with Pill Esophagitis (6)?
2. Iron Sulfate
1. What symptom is provided with Eosinophilic Esophagitis?
2. What medical history is provided (2)?
3. What appears on EGD (4)?
4. What is treatment (4)?
1. Intermittent dysphagia without odynophagia
2. Food allergies and asthma
3. a. Multiple concentric rings
b. Diffuse multiple white specks
c. Friable mucosa
d. Linear tearing of esophagus
4. a. Elimination of food allergens
b. TRIAL OF PPI - FIRST R/O GERD
c. Topical steroids - first-line
d. Leukotriene antagonists - second-line
1. What happens with food with a duodenal ulcer?
2. What happens with food with a gastric ulcer?
1. Improves - pyloric sphincter closes
2. Worsens - gastric acid secretion
1. In terms of peptic ulcers, what is penetration?
2. What are common sites of penetration?
1. Penetration = peptic ulcer tunneling into adjacent organs
2. a. Duodenal ulcers --> pancreas
b. Gastric ulcers --> left hepatic lobe
1. How do you screen for Zollinger-Ellison syndrome?
2. What is the associated syndrome?
3. Which Zollinger-Ellison syndrome is more likely to metastasize?
1. ZE = gastrinoma thus serum gastrin (>1,000) or HYPERCHLORHYDRIA
3. Sporadic metastases, not MEN1
What is the surgical management for refractory peptic ulcer disease (2)?
1. Antrectomy and Vagotomy via:
a. Billroth I: gastroDUODENOstomy
b. Billrott II: gastroJEJUNOstomy
Which patients are at risk for NSAID-induced ulcers (5)?
1. History of peptic ulcer
2. Concomitant use of steroids or anticoagulants
3. Age greater than 75
4. High-dose NSAIDs or NSAIDS + Aspirin
5. COX2 + Aspirin
What are treatment options for prevention of NSAID-induced ulcers (3)? What are their caveats?
1. PPI - first line
2. Famotidine (high-dose, not other H2B)
3. Misoprostol - prostaglandin analog, ++diarrhea
Following gastric adenoma surgical resection, what chemotherapeutic agents are used (2)?
What are medication treatment for gastroparesis (4)?
3. Tegaserod - FDA-approval, 5HT4 agonist
4. Domperidone (not U.S.)
What is a possible long-term complication for a afferent loop surgery (i.e. Billroth II)? What are two symptoms?
a. Postprandial pain
b. Diarrhea with malabsorption of fats and B12
1. What is Dumping Syndrome?
2. Describe the two phases.
1. Rapid emptying of gastric contents after meals, especially after simple carbohydrates (i.e. sucrose)
2. Early 15-30m after meals:
a. abdominal cramps
c. osmolar diarrhea
Late 90m-3h after meals
If gallstones are not seen on CT, what are other imaging modalities?
What variables suggest poor prognosis following an acute pancreatitis (4)?
1. BMI greater than 25
2. Hct greater than 50
3. High ESR/CRP
4. Rising BUN
What cancers are attributable to MEN1?
MEN1 = three Ps
- Pancreas (gastrin, insulin, VIPoma)
- Pituitary (prolactin)
What cancers are attributable to MEN2?
- Medullary thyroid carcinoma
What cancers are attributable to MEN3?
- Medullary thyroid carcinoma
- mucosal neuroma (ganglioneuromatosis)
1. For patients with cirrhosis and HCC, what are indications for transplant (3)?
2. When patients with large HCC tumors are not candidates for transplant, what is a treatment option?
3. How about small tumors?
1. a. 3 or fewer lesions less than 3 cm
b. 1 lesion less than 5 cm
c. Cirrhosis with poor liver reserve
2. Periodic transarterial chemoembolization
3. Percutaneous ablative alcohol injection or radiofrequency ablation
What are relative contraindications for hepatic resection in the setting of HCC (3)?
1. Underlying cirrhosis
2. Portal HTN
3. Hepatic dysfunction
What is another name for a gastric emptying study?
1. What are two serologic tests that suggest hemochromatosis?
2. What is the diagnostic test?
3. What is treatment if phlebotomy is not tolerated?
1. a. Elevated Transferrin (especially >55% men and >50% women)
b. Elevated Ferritin
2. HFE gene
3. Deferoxamine an iron chelator
What differentiates secretory from osmotic diarrhea?
Stool electrolytes and osmotic gap (normal 290):
- 290 MINUS 2 x (Na + K)
- Secretory < 50
- Osmotic >=125
Define acute and chronic diarrhea
Acute diarrhea < 2 weeks
Chronic diarrhea > 4 weeks
With a fecal fat test, what is the threshold for __?
Fecal fat > 14g / 24 hours = Malabsorption
1. What is normal stool osmolarity?
2. What value suggest factitious?
1. Normal = 280-300
2. Less than 250 suggests factitious
What part in a patient's description of stool suggests malabsorption?
1. What serologic labs would suggest small bowel bacterial overgrowth?
2. What two antibiotic regimens are considered for bacterial overgrowth?
1. Anemia with low B12 and high folate (from bacterial prod)
2. Augmentin or Norfloxacin
1. What OTC drug can worsen Crohn's?
2. Describe tobacco's relationship to the risk of developign Crohn's and Ulcerative Colitis?
2. Crohn's = smoking increases risk
UC = NOT smoking increases risk
Which skin lesions occur in patients with Crohn's vs. Ulcerative Colitiis?
Crohn's = Erythema nodosum
UC = Pyoderma gangrenosum
1. List the FOUR different 5-aminosalicylates
2. What is their targeted tissue?
3. Which may be useful in Crohn's?
*Targeted affect on COLON
**Mild disease of small bowel
1. What steroid-sparing drugs are used in IBD (6)?
2. Which are most useful with Crohn's?
3. Which are most useful with UC?
Azathioprine + Pred
6-Mercaptopurine + Pred
**Fistulas with Crohn's!
***Ulcerative Colitis, steroid refractory
How is treatment for Crohn's different from UC (4)?
1. Encourage smokers to stop
2. 5-aminosalicylates are less effective because of their targeted affect on the COLON
3. Metronidazole option for induction therapy, especially with MILD perianal disease
4. Budesonide used for ileocolonic disease
1. How do fiber and bulking agents treat constipation (2)?
2. How do osmotic agents work?
3. How do stimulant laxative work? What are two caveats to its use?
4. What prokinetic agent can be used?
1. Increases stool weight and colon transit speed
2. Increases water content in stool
3. Increases stool frequency and stool weight
- Discourage long-term use
- Can cause abdominal cramping
4. Tegaserod - FDA-approval
Following curative surgical resection for colon cancer, describe the surveillance frequency for:
3. CT scan
1. Colonoscopy 1, 3, and 5 years
2. CEA q3m x 3 years
3. CT q1year x 3 years
What test is used for Primary Biliary Cirrhosis?
1. How high to AST and ALT rise in viral or drug-induced hepatitis?
2. APAP toxicity?
3. EtOH hepatitis?
4. Autoimmune hepatitis?
3. <500, typically
How and when should household and intimate contacts of those with HAV be treated?
Serum immune globulin within two weeks
1. How high of a DNA level should raise concern?
2. What is a typical false positive result?
1. >100,000 indicates viral replication
2. Isolated positive IgG anti-HBc
What are indications for treatment of HBV (4)?
1. ALT > 2x normal
2. HBV DNA >100,000
3. Liver biopsy evidence of cirrhosis
4. Pre-cancer treatment
What are goals of therapy for HBV treatment (3)?
1. Improved LFTs
2. Lower HBV DNA
3. Seroconversion HBeAg to anti-HBe
-OR-maybe clearance of HBsAg
Which drug should not be used in certain patients with HBV?
Child-Pugh B or C should NOT RECEIVE interferon because it may precipitate flare
What are treatment drug options for HBV (4)? Which one causes resistance? Which should be avoided in ACUTE HBV?
*More resistance following treatment
**Causes hepatonecrosis in acute HBV
Which patients with HBV should be screened for HCC?
1. Asians with family history of HCC
2. Asian men older than 40
3. Asian women older than 50
4. Africans older than 20
1. Which patient genotype of HCV can undergo treatment without liver biopsy?
2. What variables confer good clearance after treatment (5)?
1. Genotype 2 or 3
2. a. Genotype 2 or 3
b. Age younger than 40
c. RNA < 800,000
d. Minimal or no fibrosis
e. Female sex
1. What is drug treatment(s) for patients with HCV?
2. Which patients should be treated (3)?
1. a. Genotype 1 = Interferon + ribavirin + boceprevir/telaprevir
b. Genotype 2/3 = Interferon + ribavirin
2. a. Compensated disease: no ascites, encephalopathy, bleed
b. Detectable HCV RNA
c. Elevated LFTs
What is the maximal APAP daily dose for those with alcoholic liver disease?
2 grams daily
What rheumatologic labs can be positive in Autoimmune Hepatitis (4)?
2. Anti-smooth muscle antibody
3. Anti-LKM1 (Liver Kidney Microsome 1)
1. What is treatment for Autoimmune Hepatitis?
2. What is treatment for recurrence?
3. What medication can trigger Autoimmune Hepatitis, thus is contraindicated?
1. Prednisone +/- Azathioprine when SYMPTOMATIC
1. What are diagnostic criteria for Primary Biliary Cirrhosis (2)?
2. What is treatment?
1. a. Anti-MITOCHONDRIAL antibodies
b. Liver biopsy
2. Ursodeoxycholic acid (Ursodiol)
What are treatment options for Hepatic Encephalopathy (3)?
3. Neomycin - nephrotoxic and ototoxic
How does an HCC appear on 4-phase liver CT?
Rapidly enhances then rapidly declines
How does a cavernous hemangioma appear on 4-phase liver CT?
Peripheral nodular enhancement, then "fills in" then opacifies
How does a hepatic abscess appear on 4-phase liver CT?
1. Round and does not enhance
2. Surrounded by irregular rim-like enhancement
1. How does a Hepatic Adenoma appear on 4-phase liver CT?
2. What hormone is Hepatic Adenomas sensitive to?
1. Peripheral enhancement, followed by isodense and then hypodense
How does a Focal Nodular Hyperplasia appear on 4-phase liver CT?
Solitary with central scar
1. What tumor markers are used with Cholangiocarcinoma and what is the cutoff in one of these tests?
2. What treatment option does not improve survival?
1. a. CA 19-9 > 100
2. Chemotherapy does NOT improve survival
How long should PPI therapy be continued for extraesophageal manifestations of GERD?
What is treatment for Entamoeba Histolitica?
2. Paromomycin or Iodoquinol (antiparasitic)
At what INR should endoscopy be reversed?
INR > 3
If endoscopy is negative for UGI bleed in patients with aortic aneurysm repair, then do a __ for a __.
...CT scan ... aorto-enteric fistula
What common GI medication combined with a common cardiac stent medication raises risk for repeat MI?
Clopidogrel and Omeprazole - decreases clopidogrel inhibitory effect on platelets
1. What is the illness script for Whipple's Disease?
2. What is the treatment?
1. Male farmer who presents with arthritis and malabsorptive diarrhea.
What are treatment options for C.diff based on degree of illness?
1. Metronidazole 500 TID x 10-14d
2. Vancomycin 125 PO QID x 10-14d
Severe: WBC > 15, Cr 1.5x
1. Vancomycin 125 QID x 14d OR
Severe COMPLICATED: Megacolon, shock
1. Vancomycin 500 QID plus Metro 500IV q8h
2. (Ileus --> Vanco PR QID)
What diagnostic test is available to test pancreatic insufficiency?
Secretin stimulation test for the pancreas
What is a diagnostic test for a Zenker diverticulum?
What is the sequence of tests for work-up of acute pancreatitis?
Abdominal ultrasound --> CT abdomen after 48h if persistent or severe
What is Fitz-Hugh-Curtis syndrome?
Gonococcal or chlamydial perihepatitis
List the differential based on ascites fluid analysis
Ascitic Fluid Protein < 2.5 g/dL and
- SAAG > 1.1 = Cirrhosis
- SAAG < 1.1 = Nephrotic syndrome
Ascitic Fluid Protein > 2.5 g/dL and
- SAAG > 1.1 = R-CHF, Budd-Chiari
- SAAG < 1.1 = Malignancy, TB
***SAAG = serum MINUS ascites albumin
If a patient develops diarrhea after __ hours, think __ (3).
1. 6 hours --> Staph or Bacillus cereus
2. 8-14 hours --> Clostridium perfingens
3. >14 hours --> viral or Enterohemorrhagic E.Coli
What is the criteria for Lynch Syndrome (HNPCC)?
Three affected family members
One under 50yo
1. How do you calculate Transferrin Saturation?
2. What percentage would suggest Hemochromatosis?
1. Iron / TIBC
2. Greater 55% men and 50% women
What two lab abnormalities would warrant Albumin to be added to Cefotaxime for SBP?
1. Creatinine greater than 1.5
2. Bilirubin greater than 4
After colectomy in a patient with FAP, what screening test should be routinely done, and why?
EGD to evaluate for Ampulllary Adenocarcinoma
1. What are symptoms of Hepatopulmonary Syndrome in cirrhosis (2)?
2. What is a serologic finding?
3. What is a diagnostic study?
1. DOE and platypnea (SOB relieved when supine)
2. PO2 < 70
3. TTE with microbubbles in left atrium after 3-6 cardiac cycles
How often should patients with Ulcerative Colitis have colonoscopy?
If only UC proctitis, every 10 years.
If more UC or Fhx or PSC, every 1-2 years
What is appropriate treatment for short-bowel diarrhea after bowel resection, and why?
PPI because increased acid secretion causes neutralization of pancreatic enzymes, leading to diarrhea
1. How do you calculate a discriminant function?
2. How does the score influence management?
3. What are contraindications to treatment (3)?
1. DF = 4.6 x (delta-PT) + Bilirubin
2. DF > 32 means 50% mortality thus survival benefit for corticosteroids in EtOH hepatitis and hepatic encephalopathy
- renal failure
- concomitant infection
1. What medication is appropriate for constipation-predominant IBS?
2. What medication would not be effective, and why?
1. Lubiprostone - increases intestinal water
2. Tricyclic antidepressants - increase constipation due to anticholinergic efffect
1. What are features of a high-grade adenomatous polyp that would warrant repeat colonoscopy in 3 years (4)?
2. What type of polyp might warrant repeat colonoscopy in 2-6 months?
1. a. More than 3 (non-hyperplastic) adenomas
b. More than 1 cm
c. Villous adenoma
d. High-grade dysplasia
2. Sessile polyp that was not fully resected
1. What reduces the sensitivity of H.pylori urea breath test and the H.pylori stool test (2)?
2. What test should be collected instead?
1. PPI in past two weeks
2. Bismuth in past two weeks
***Choose H.pylori serum test!
What are three nonacute indications for cholecystectomy?
1. Polyps greater than 1-mm
2. Stones greater than 3-cm
3. Porcelain (calcified) gallbladder