Gastrointestinal Step Up Flashcards
(263 cards)
1
Q
what do you do if a patient has a positive FOBT? even if they are asymptomatic?
A
colonscopy
2
Q
most sensitive and specific test for colon cancer
A
colonscopy
3
Q
what test is complementary to flexible sigmoidoscopy in evaluating CRC?
A
barium enema
4
Q
what is CEA useful for?
A
NOT SCREENING
- used for baseline and recurrence surveillance
5
Q
what pre-op value of CEA implies worse prognosis in CRC?
A
> 5 ng/mL
6
Q
what type of polyps have the highest malignant potential?
A
villous adenomas (Vs. tubular adenomas)
7
Q
polyps plus osteomas, dental abnormalities, benign soft tissue tumors, desmoid tumors and/or sebaceous cysts
A
Gardner’s syndrome
- risk of CRC is 100% by age 40
8
Q
polyps plus cerebellar medulloblastoma or glioblastoma multiforme
A
Turcot’s syndrome
9
Q
multiple hamartomas throughout entire GI tract and pigmented spots around oral mucosa, lips and genitalia
A
Peutz-Jegher’s syndrome
10
Q
Lynch syndrome I
A
site specific CRC - early onset CRC
11
Q
Amsterdam Criteria I
A
for dx. Lynch syndrome
- atleast 3 relatives with CRC (one first degree)
- 2+ generations
- one onset before age 50
- FAP has been excluded
12
Q
Lynch syndrome II
A
early onset CRC plus other cancers (breast, endometrial ca, skin, stomach, pancreas, brain etc)
13
Q
MCC of large bowel obstruction in adults
A
CRC
14
Q
MC presenting symptom in CRC
A
abdominal pain
15
Q
pt suspected of having CRC presents with anemia, weakness, occult blood in stool, melena, and iron deficiency anemia - where is the tumor likely located?
A
right sided tumors i.e. cecum
- lack of obstructive symptoms
16
Q
pt suspected of having CRC presents with alternating constipation and diarrhea; he also has hematochezia - where is the tumor likely located?
A
left sided tumor
17
Q
MC symptoms of rectal cancer
A
hematochezia with tenesmus and incomplete feeling of evacuation due to rectal mass
18
Q
in what case of CRC is radiation therapy indicated?
A
rectal cancer
19
Q
follow-up of CRC after resection includes? (4)
A
- stool guaic test
- annual CT scan of abdo/pelvis and CXR for 5 years
- colonscopy at 1 year and then every 3 years
- CEA levels
20
Q
MC non-neoplastic polyps
A
hyperplastic (metaplastic) polyps
- commonly removed even though they are benign
21
Q
MC type of neoplastic polyp
A
tubular adenoma
22
Q
at what size is there greater risk of malignant potential in a colon polyp?
A
> 2.5 cm
23
Q
what shape of polyp is most likely to be malignant
A
sessile (vs. pedunculated)
24
Q
MC location of diverticulosis
A
sigmoid colon
25
test of choice for diagnosing diverticulosis
barium enema
26
tx. of diverticulosis
high-fiber diet (bran) to increase stool bulk
27
complications of diverticulosis
painless rectal bleeding
| diverticulitis
28
how do you manage painless rectal bleeding as a complication of diverticulosis
usually stops on its own
colonscopy - to locate site of bleeding
if bleeding persists or recurs - consider segmental colectomy
29
pt presents with fever, LLQ and leukocytosis; you find inflammation of pericolic fat, bowel wall thickening and pericolic fluid collection - what should you consider?
diverticulitis
30
complications of diverticulitis
abscess formation - drained surgically
colovesical fistula
obstruction
colonic perforation - peritonitis
31
Dx. test of choice in diverticulitis
CT scan w/ oral and IV contrast
| - avoid barium enema and colonscopy due to risk of perforation
32
Tx. of uncomplicated diverticulitis
IV antibiotics, bowel rest (NPO) and IV fluids
| - if sx persist for 3-4 days, may need to consider surgery
33
Tx. of complicated diverticulitis
surgery - resection of involved segment
34
tortuous, dilated veins in the submucosa of the proximal wall of colon
Angiodysplasia of colon
| - aka. AV malformation or vascular ectasia
35
MC sx. of angiodysplasia of colon
lower GI bleeding - usually stops on its own
36
Dx. of angiodyplasia
colonoscopy - preferred over angiography
37
Tx. of angiodysplasia of colon
usually not needed
- colonscopy coagulation of lesion if frequent bleeding
- right hemicolectomy if persistent bleeding
38
what condition is angiodysplasia (oddly) associated with?
aortic stenosis
39
four "causes" of acute mesenteric ischemia
arterial embolism
arterial thrombosis
non-occlusive mesenteric ischemia
venous thrombosis
40
pt presents with acute onset, severe abdominal pain; abdominal exam is benign - what test(s) should you order in order to get a diagnosis?
check lactate level
plain films - R/O other causes of pain
mesenteric angiography - test of choice for acute mesenteric ischemia
41
what classic finding can be seen on XR/barium enema in ischemic colitis?
thumb-printing (due to thickened edematous mucosal folds)
42
Tx. of choice for arterial causes of acute mesenteric ischemia
direct intra-arterial infusion of papaverine (vasodilator) into SMA during arteriography
43
what drugs should be avoided in mesenteric ischemia?
vasopressors
44
older patient presents with dull abdominal pain classicaly following every meal; there has been significant weight loss (bc the patient now seems to be avoided eating) - what test do you order to confirm your diagnosis?
chronic mesenteric ischemia
| - order mesenteric angiography
45
Tx. of chronic mesenteric ischemia
surgical revascularization
46
patient presents with signs and symptoms of large bowel obstruction; radiographic imaging confirms this - however, there is no actual mechanical obstruction - dx?
Ogilvie's syndrome
47
what is the sign of impending bowel rupture?
colonic distention with diameter > 10 cm
| - you need to decompress immediately
48
patient who was recently tx. with clindamycin develops profuse watery diarrhea and crampy abdominal pain - dx?
pseudomembranous colitis
| - usually occurs after course of ampicillin, clindamycin or cephalosporing antibiotics
49
how do you confirm diagnosis of pseudomembranous colitis?
C.difficle toxin in stool
| abdominal XR to r/o complications
50
DOC for pseudomembranous colitis
```
oral metronidazole (can also be given IV)
- if this does not work, try oral vancomycin
```
51
what drug can be used as adjuvant tx. to improve the diarrhea associated with pseudomembranous colitis?
cholestyramine
52
twisting of loop of intestine around its mesenteric attachment site, most commonly in the sigmoid colon
colonic volvulus
53
RFs for colonic volvulus
```
chronic illness
age
institutionalization
CNS disease
chronic constipation/antimotility drugs
laxative abuse
prior abdominal surgery
```
54
plain film findings in
- sigmoid volvulus (1)
- cecal volvulus (2)
(1) omega loop sign - indicates dilated sigmoid colon
| (2) distention of cecum/small bowel; coffee bean sign indicating large air-fluid level in RLQ
55
preferred diagnostic test for sigmoid volvulus
sigmoidoscopy - it also usually successfully decompresses and untwists it leading to tx. as well - but these commonly recur, so you should offer your patient an elective sigmoid resection
56
what is used to measure disease severity in liver cirrhosis and serves as a predictor of morbidity/mortality?
```
Child's classification
- class A is mild disease; class C is severe dz
```
57
MCC of cirrhosis
alcoholic liver dz
| chronic viral infection - hepC
58
gold standard test for diagnosis of liver cirrhosis
liver biopsy
59
how can you lower portal HTN?
transjugular intrahepatic portal-systemic shunts (TIPS)
60
how do you tx. someone with perforated esophageal varices?
1. IV fluids - stabilize BP
2. IV octreotide - 3-5 days
3. upper GI endoscopy with variceal ligation/banding or sclerotherapy
4. IV antibiotics prophylactically
61
how do you prevent rebleeding in someone with esophageal varices?
tx. with non-selective B-blockers
62
what tests should be done in suspected ascites?
abdominal USG - can detect as little as 30 ml fluid
| paracentesis
63
indications for paracentesis
new onset ascites
worsening ascites
suspected spontaneous bacterial peritonitis
64
serum ascites-albumin gradient
if > 1.1 g/dL = portal HTN
| if < 1.1 g/dL = must consider other causes of ascites
65
step-wise tx. of ascites
1. Na+ and water restriction
2. spironolactone
3. furosemide - not > 1L/day
4. therapeutic paracentesis
66
what test should patients with cirrhosis have done?
endoscopy to assess for presence of esophageal varices - if present, tx. with B-blocker
67
precipitants of hepatic encephalopathy
```
alkalosis
hypokalemia
sedating drugs - narcotics, sleep pills
GI bleeding
systemic infection
hypovolemia
```
68
CF of hepatic encephalopathy
changes in mental function
asterixis
rigidity/hyperreflexia
fetor hepaticus - musty odor of breath
69
Tx. of hepatic encephalopathy
lactulose
| neomycin - kills GI flora that produces ammonia
70
hepatorenal syndrome
progressive renal failure secondary to renal hypoperfusion resulting from vasoconstriction of renal vessels (afferent arteriole) in the setting of advanced liver disease
71
CF of hepatorenal syndrome
```
azotemia
oliguria
hyponatremia
hypotension
low U-Na+ (<10)
no improvement after 1.5 L saline = diagnostic
```
72
diagnosis of hepatoregnal syndrome
decreased GFR In absence of shock, proteinuria or other clear cause of renal failure and a failure to respond to 1.5L normal saline bolus
73
Tx. hepatorenal syndrome
liver transplantation
| medical - midodrine, octreotide
74
a patient with ascites develops fever, vomiting, rebound abdominal tenderness and changes in mental status - what should you consider?
spontaneous bacterial peritonitis
| - MC agent is E.coli
75
how do you confirm diagnosis of spontaneous bacterial peritonitis?
paracentesis - WBC > 500, PMNs > 250
| - do gram stain and culture before picking antibiotic (usually 3rd gen cephalosporin)
76
how do you monitor progress in spontaneous bacterial peritonitis?
repeat paracentesis in 2-3 days to document a decrease in ascitic fluid PMNS < 250
77
how do you tx. coagulopathy associated with cirrhosis?
fresh frozen plasma
78
how do you diagnose Wilson's disease?
increased LFTs
increased PT/PTT - coagulopathy
decreased serum ceruloplasmin levels
biopsy - increased copper concentration
79
young patient presents with liver disease and neurological signs, including parkinsonian symptoms and psychosis/personality changes - what should you consider?
Wilson's disease - copper commonly accumulates in liver and brain
- if dx, should screen first degree relatives as well
80
Tx. of Wilson's disease
symptomatic pts - D-penicillamine (chelator)
| asymptomatic/pregnant pts - Zinc (prevents uptake of dietary copper)
81
what can cause secondary hemochromatosis?
multiple blood transfusions
| chronic hemolytic anemias
82
complications of hemochromatosis
```
cirrhosis
cardiomyopathy
diabetes mellitus
arthritis - 2/3 MCP, hips and knees
hypogonadism
hypothyroidism
hyperpigmentation of the skin
```
83
what should you order if a pt presents with mild elevations of ALT and AST levels?
iron studies - if elevated, obtain a liver biopsy to dx. hemachromatosis
84
lab findings in hemochromatosis
elevated serum iron, ferritin and transferrin saturation; decreased TIBC
- liver biopsy is diagnostic w/ elevated iron stores
85
Tx. of choice for hemochromatosis
repeated phlebotomies
86
how do you diagnose hepatic adenoma?
CT scan, USG or hepatic arteriography (most accurate, but invasive)
87
how do you tx. hepatic adenoma?
stop OCPs - if may regress
| surgical resection of tumors > 5cm
88
how can you diagnose a cavernous hemangioma?
USG or CT scan w/ contrast
| - biopsy is c/i due to risk of hemorrhage
89
Tx. of cavernous hemangioma
most do not require tx; consider resection if pt is symptomatic or there is high risk of rupture
90
what type of liver tumor is similar to hepatic adenoma on imaging but has no malignant potential and is not assoc. with OCP use?
focal nodular hyperplasia
| - usually asx and no tx. needed
91
what type of liver cancer is associated with hepB/C and cirrhosis, is generally unresectable w/ a short survival time?
non-fibrolamellar (most common)
92
what type of hepatocellular ca. is resectable with longer survival time, usually seen in young adults?
fibrolamellar type
93
what should you consider in a patient with liver cirrhosis, a palpable mass and elevated AFP?
hepatocellular carcinoma
94
what is needed for the definitive diagnosis of hepatocellular ca?
liver biopsy
95
what tumor marker is elevated in HCC?
AFP
| - useful as screening tool and for monitoring response to therapy
96
paraneoplastic syndromes caused by HCC?
```
erythrocytosis
thrombocytosis
hypercalcemia
carcinoid syndrome
hypertrophic pulmonary osteodystrophy
hypoglycemia
high cholesterol
```
97
Tx. of hepatocellular carcinoma
liver resection or liver transplant
98
your obese, diabetic patient comes in for routine blood work and results show mildly elevated liver enzymes - dx? tx?
most likely non-alcoholic steatohepatitis
| tx. is unclear
99
a young male comes in because he noticed he turned yellow after fasting for the past 3 days; you do blood work and find isolated elevated UCB - dx?
Gilbert's disease
| - decreased activity of hepatin uridine diphosphate glucoronyl transferase
100
a patient comes in with melena, hematemesis, jaundice and RUQ pain; upper GI endoscopy shows blood draining out of ampulla of Vater
hemobilia
| - blood draining into duodenum via CBD
101
what is the diagnostic test for hemobilia
arteriogram
102
consequences of liver cysts associated with polycystic kidney disease?
rarely lead to hepatic fibrosis or failure; usually asymptomatic and dont usually need treatment
103
a patient presents with a diagnosed large cyst on right lobe of liver; he currently has RUQ pain - what are you worried about? how would you treat this?
- hydatid liver cyst caused by Echinococcus; dont want it to rupture bc can result in anaphylactic shock
- tx. is surgical resection and mebendazole
104
MC location for liver abscesses
right liver lobe
105
how do you diagnose a liver abscess?
ultrasound or CT scan
| usually also have elevated LFTs
106
how do you tx. a liver abscess?
IV antibiotics
| percutaneous drainage of abcess (sometimes surgical drainage is necessary)
107
a homosexual man presents with fever, RUQ pain, NV, hepatomegaly and bloody diarrhea - what should you consider?
amebic liver abscess (entameoba histolytica)
108
how can you diagnose amebic liver abscess?
serology - IgG enzyme immunoassay
109
Tx. of amebic liver abscess?
IV metronidazole
| - may require therapeutic aspiration if large or not going away with medical therapy
110
occlusion of hepatic venous outflow leading to hepatic congestion and microvascular ischemia
Budd Chiari syndrome
111
causes of Budd Chiari syndrome
```
hypercoagulable states
myeloproliferative disorders
pregnancy
chronic inflammatory diseases
infection
various cancers/trauma
```
112
how do you diagnose Budd Chiari syndrome?
hepatic venography
| serum ascites albumin gradient > 1.1 g/dL
113
how do you tx. Budd Chiari syndrome?
balloon angioplasty with stent in IVC
| portocaval shunts
114
at what level of bilirubin does jaundice become evident?
total bilirubin > 2 mg/dL
115
which form of bilirubin is tightly bound to albumin (water insoluble) and cannot be excreted in urine; also if unbound from albumin, can cross BBB and become toxic?
unconjugated bilirubin - indirect
116
dark urine and pale stools mean...
conjugated bilirubinemia
117
a patient comes in with jaundice, lighter stools and dark urine; he also complains of pruritus - lab tests reveal elevated ALP and serum cholesterol; you notice he has skin xanthomas - what should you consider?
cholestasis - blockage of bile flow with resultant increase in CB levels
- he is at risk for malabsorption of fat and fat soluble vitamins
118
in what scenarios are AST and ALT mildly elevated (hundreds)?
alcoholic hepatitis
| chronic viral hepatitis
119
in what scenarios are AST and ALT moderately elevated (high hundred to thousands)
acute viral hepatitis
120
in what scenarios are ALT and AST extremely elevated (> 10 000)?
ischemia, shock liver
acetaminophen toxicity
severe viral hepatitis
121
if you find an elevated ALP in a patient, what is the next test you should order?
GGT - to see if ALP is hepatic in origin (GGT will also be elevated)
122
cholestatic LFTs
ALP and GGT
| - if these are positive, obtain abdominal or RUQ ultrasound
123
biliary colic
cardinal sx of gallstones; temporary obstruction of cystic duct by gallstone
124
boa's sign
referred subscapular pain of biliary colic
125
test of choice to dx. cholelithiasis (gallstones)
RUQ ultrasound
126
Tx. of gallstones
asymptomatic - do nothing
| symptomatic - laparascopic cholecystectomy
127
what do you do if a pt refuses laparascopic cholecystectomy?
rx. ursodeoxycholic acid - but this is expensive and has a high risk of recurrence; used in pts who are not good surgical candidates
128
signs of acute cholecystitis
RUQ pain
Murphy's sign - pathognomic
hypoactive bowel sounds
low grade fever/leukocytosis
129
USG findings show thickened gallbladder wall, pericholecystic fluid, distended gallbladder and presence of stones - what is the dx?
acute cholecystitis
130
what study do you perform to assess complications of acute cholecystitis?
CT scan
131
what test do you do if the USG findings in suspected acute cholecystitis are inconclusive?
HIDA scan - gallbladder is not visualized 4 hours after injection
132
Tx. for acute cholecystitis
admit to hospital - supportive measures include IV fluids, antibiotics, analgesics, NPO
133
what is the most appropriate next step once a patient is recovered from acute cholecystitis (or stable)
laparascopic cholecystecomy - best w/in 24-48 hours
134
Tx of choice for acalculous cholecystitis?
emergent cholecystectomy
| - if pt is to ill for surgery, do percutaneous drainage with cholecystomy
135
pt presents with RUQ/epigastric pain and jaundice; labs show elevated total and direct bilirubin and ALP - dx? and test? and tx?
choledolithiasis
- do USG first followed by ERCP (gold standard)
- tx. ERCP stone removal and sphincterectomy and stent
136
pt presents with RUQ pain, jaundice and fever; soon after evaluation she develops signs of septic shock and altered mental state - what is the dx? and initial study?
cholangitis - medical emergency
| - initial study is RUQ ultrasound (directs next step)
137
how do you approach patient with cholangitis?
blood cultures
IV fluids
IV antibiotics - based on culture results
decompress CBD when pt is stable
138
tests to do in cholangitis after RUQ ultrasound?
cholangiography:
PTC - if bile ducts are dilated
ERCP - if bile ducts are normal
- can only do these once patient has been afebrile for 48 hours and patient is stable; used to diagnose and decompress the CBD
139
most feared complication of cholangitis?
hepatic abscess
140
what do you do with a finding of porcelain gallbladder?
prophylactic cholecystectomy
| - 50% will develop cancer
141
pt presents to you with jaundice and pruritus of the skin; she also feels more tired lately and has been losing weight; she is scared this is related to her ulcerative colitis - what are you thinking of?
primary sclerosing cholangitis
| - do ERCP and PTC to diagnose
142
biopsy findings in ERCP and PTC
multiple bead-like strictures and dilations of both intra and extrahepatic bile ducts
143
tx. of primary sclerosing cholangitis
liver transplant
| ERCP w/ stenting to relieve symptoms of strictures; cholestryamine to help with pruritus
144
pt with UC comes in complaining of severe pruritus at night; she has some RUQ discomfort and fatigue, you do tests and note she has high cholesterol and xanthelasmas - dx? what tests should you order?
consider primary biliary cirrhosis
| order antimitochondrial ab's and liver biopsy to confirm diagnosis
145
lab findings in primary biliary cirrhosis
cholestatic LFTs
positive AMAs
elevated cholesterol, HDL
elevated IgM
146
what drug has been shown to slow progression of primary biliary cirrhosis?
ursodeoxycholic acid
| - but liver transplant is only curative tx
147
Klatskin tumor
cholangiocarcinoma - in proximal 1/3 of CBD involving junction of right and left ducts; MC but worst prognosis bc it is unresectable
148
RFs for cholangiocarcinoma
primary sclerosing cholangitis
UC
choledochal cysts
clonorchis sinensis (Hong Kong)
149
a woman presents with epigastric pain, jaundice and fever; a RUQ mass is felt on physical exam - what tests should you order? what is your suspected diagnosis?
dx - choledochal cyst
| tests - USG first, ERCP is definitive test
150
choledochal cyst
cystic dilation of biliary tree in either extrahepatic or intrahepatic ducts
151
Tx. of choledochal cysts
surgery - complete resection of cyst with biliary-enteric anastomosis to restore continuity of biliary system with bowels
152
pt comes in with her 5th episode of biliary colic, you do another USG and again find no gallstones - what study should you consider next? diagnosis?
possible biliary dyskinesia (motor dysfunction of sphincter of oddi)
- order HIDA scan (w/ CCK IV to determine ejection fraction of gallbladder
153
tx. of biliary dyskinesia
laparscopic cholecystectomy or endoscopic sphincterectomy
154
Rovsing's sign
appendicitis
| - deep palpation in LLQ causes pain in RLQ
155
Psoas sign
appendicitis
| - RLQ pain when right thigh is extended as patient lies on left side
156
obturator sign
appendicitis
| - RLQ pain when flexed right thigh is internally rotated when patient is supine
157
dx. of appendicitis
clinical diagnosis!!
| - can do a CT scan or USG if uncertain or atypical presentation
158
what nutritional deficiency is someone with a carcinoid tumor at risk for?
niacin deficiency - pellagra
| - use up all tryptophan to make serotonin
159
tx. of carcinoid tumor
surgery
| - if unable to resect: octreotide
160
drugs that can cause pancreatitis
diuretics - thiazides, loops
IBD - sulfasalazine, 5ASA
immunosuppressants - azathioprine, asparaginase
epileptic drugs - valproate
AIDs - didanosine, pentamidine
antibiotics - metronidazole, tetracycline
161
main RFs for pancreatitis
alcohol
gallstones
post-ERCP - 10% of pts
blunt abdominal trauma - children
162
classic pain seen in acute pancreatitis
epigastric pain that radiates to the back; worse when supine and after meals
163
Ranson's admission criteria for acute pancreatitis
GA-LAW
- glucose > 200 mg/dL
- age > 55 yo
- LDH > 350
- AST > 250
- WBC > 16000
164
Ranson's initial 48 hr criteria for acute pancreatitis
C-HOBBs
- calcium < 8 mg/dL
- Hct decreased by > 10%
- PaO2 < 60
- BUN increase > 8 mg/dl
- base deficit > 4 mg/dL
- fluid sequestration > 6L
165
diagnostic test for acute pancreatitis
CT abdomen
166
indications for ERCP in acute pancreatitis
severe gallstone pancreatitis w/ biliary obstruction OR to identify causes of recurrent pancreatitis
167
how do you tell sterile from infected pancreatic necrosis?
CT guided percutaneous aspiration w/ gram stain and culture of aspirate
- infected needs surgical debridement and antibiotics
168
diagnostic test and tx. of pancreatic pseudocyst?
CT scan
| - treat cysts > 5 cm with drainage (percutaneously or surgically)
169
complications of acute pancreatitis
```
hemorrhagic pancreatitis
ARDS
pancreatic ascites/pleural effusion
ascending cholangitis
pancreatic abscess
```
170
Tx, of mild pancreatitis
NPO - bowel rest
IV fluids
pain control - fentanyl or meperidine
NG tube if vomiting or ileus present
171
tx. of severe pancreatitis
pts with 3+ Ranson's criteria should be admitted to ICU
- enteral nutrition with nasojejunal tube w/in 72 hours
- imipenem if > 30% necrosis present
172
pt comes in with chronic epigastric pain, steatorrhea and diabetes mellitus - you do XR and find calcifications - dx?
chronic pancreatitis
173
initial study of choice for chronic pancreatitis
CT scan
| - ERCP is gold standard but is not done routinely
174
what is the stool elastase test for?
to diagnose malabsorption secondary to pancreatic exocrine insufficiency
175
what drugs should be given with pancreatic enzyme supplements?
H2 blockers
| - prevent degradation of enzymes in stomach acid
176
surgery procedure most commonly done for relief of incapacitating pain due to chronic pancreatitis?
pancreaticojejunostomy
177
pancreatic cancer of head - symptoms?
weight loss
steatorrhea
obstructive jaundice
178
pancreatic cancer of body/tail - symptoms?
pain
| weight loss
179
CF of pancreatic cancer
```
abdominal pain - vague, dull ache
jaundice - increased CB and ALP
weight loss/anorexia
recent glucose intolerance
migratory thrombophlebitis
palpable gallbladder
```
180
preferred test for assessment and diagnosis of pancreatic cancer
CT scan
181
most sensitive test for dx. pancreatic cancer
ERCP
182
patient presents with small upper GI bleed from duodenum; in his history he has previously had aortic graft surgery - what should you do?
perform endoscopy or surgery immediately - you are afraid of lethal aortoenteric fistula
183
Diuelafoy's vascular malformation
submucosal dilated arterial lesions that can cause massive upper GI bleeding
184
other than blood, what can cause dark stools?
```
charcoal
bismuth
iron
spinach
licorice
```
185
initial test in hematemesis
upper GI endoscopy
186
initial test in hematochezia
rule of anorectal cause
| order colonoscopy
187
initial test in melena
upper GI endoscopy
| - if nothing found, order colonscopy
188
initial test in occult blood
colonoscopy
189
elevated PT may be indicative of.. (4)
liver dysfunction
vit K deficiency
consumption coagulopathy
warfarin therapy
190
what lab finding may be elevated in Upper GI bleeding?
BUN-Cr ratio - the higher the ratio, the more likely the bleeding is from an upper GI source
191
most accurate test for Upper GI bleeding
upper endoscopy
192
what is top priority in pt with GI bleed?
fluid resuscitation if hemodynamically unstable
193
what is usually the initial procedure in GI bleed?
nasogastric tube - empties stomach, prevents aspiration and assesses fluid
194
what is the general rule for replacement fluids in pt who has lost a lot of blood due to GI bleed?
3 ml crystalloid fluids for every 1 ml of blood lost
195
what test definitively locates the point of bleeding - usually used in lower GI bleeds?
arteriography
| - should be performed during active bleeding and may be potentially therapeutic
196
Tx. for upper GI bleeding
EGD with coagulation of bleeding vessel
| - repeat endoscopic therapy or surgical intervention if the bleeding continues
197
indications for surgery in GI bleeding (5)
1. hemodynamically unstable patients despite all interventions
2. severe initial bleed or recurrence
3. longer than 24 hours
4. visible vessel at base of ulcer
5. ongoing transfusion - 5 units w/in 4-6 hrs
198
main RFs for squamous cc. of esophagus
```
alcohol
tobacco use
diet, HPV, achalasia, Plummer-VInson
caustic injury
nasopharyngeal carcinoma
```
199
main RFs for adenocarcinoma of esophagus
GERD and Barret's esophagus
200
what test can confirm diagnosis of esophageal ca?
upper endoscopy with biopsy and brush cytology
| - if negative, do a CT scan
201
what test is usually the first to be done if a patient presents with dysphagia?
barium swallow
202
what test is done to stage esophageal cancer?
transesophageal ultrasound
203
Tx of esophageal cancer
surgery for stages 0,1,2a - localized to esophagus; chemo + radiation before surgery may prolong survival
204
incomplete relaxation of LES and aperistalsis of esophagus are seen in?
achalasia
205
type of dysphagia common in achalasia
dysphagia for both solids and liquids (vs. esophageal ca. it is initially for solids, then liquids)
206
clinical features characteristic of achalasia
dysphagia - drink lots of water while eating, move around, twist etc. to push it down
regurgitation of food
complications of aspiration
207
confirmatory test for achalasia
manometry
| - shows failure of LES relaxation (increased pressure) and aperistalsis of esophageal body
208
what should patients with achalasia be monitored for and how?
squamous cell ca. of esophagus
| - do surveillance esophagoscopy to detect tumor at early stage
209
initial Tx. for achalasia
medical
- try antimuscarinic agenst, sublingual nitro, long acting nitrates or CCBs
- improve swallowing in early stages
210
definitive "palliative" tx. for achalasia
pneumatic dilation
| - botox injections may be effective but need to be repeated every 2 years
211
in pts who do not respond to dilation therapy for achalasia, what can you do?
surgery - heller myotomy
212
patient presents with chest pain mimicking angina that radiates to the jaw; he also complains of dysphagia - diagnosis and test?
possibly diffuse esophageal spasm
- should R/O cardiac causes of pain
- upper GI barium swallow
213
manometry findings in diffuse esophageal spasm?
diagnostic - simultaneous, multiphasic, high amplitude, repetitive contractions; normal relaxation of LES
214
Tx. of diffuse esophageal spasm
antispasmolytics - nitrates and CCBs
| TCAs - may provide sx relief
215
which type of esophageal hiatal hernias are benign and associated with GERD?
sliding hernia
216
which type of esophageal hernias can become strangulated, enlarge over time so that whole stomach is in thorax and need to be tx. surgically?
paraesophageal hiatal hernia
217
complications of sliding hiatal hernias
GERD
aspiration
esophagitis
218
complications of paraesophageal hernias
strangulation
obstruction
hemorrhage
219
Tx. of sliding hiatal hernia
medical - anatacids, small meals, elevation of head when sleeping
surgery - Nissen's fundoplication
220
Tx. of paraesophageal hernia
elective surgery to prevent complications
221
alcoholic pt presents with hematemesis; last night he binge drank and has been vomiting ever since - likely dx?
Mallory-Weiss syndrome
| - ruptured submucosal aa of distal esophagus and proximal stomach
222
first step in Mallory-Weiss syndrome?
upper endoscopy - diagnostic
223
Tx. of Mallory-Weiss syndrome
90% heal on their own
can try vasopressin, endocscopic injection or electrocautery
if still continues, surgery (oversew the tear) or angiographic embolization
224
pt presents with dysphagia, glossitis and iron deficiency anemia?
Plummer-Vinson syndrome - upper esophageal webs
225
what are patients with Plummer-Vinson syndrome at risk for?
SCC of oral cavity, hypopharynx and esophagus
226
Tx. of Plummer-Vinson syndrome
esophageal dilation
227
what does ingesting alkali do to you esophagus?
liquefactive necrosis with full thickness necrosis; may be complicated with stricture formation and esophageal cancer
228
tx. of necrosis from alklai ingestion
esophagectomy
- avoid vomiting, oral intake and gastric lavage
- steroids and antibiotics
- bougienage for strictures
229
pt presents with dysphagia, regurgitation, bad breath and chronic cough - what can you suspect?
Esophageal diverticulum
230
pt presents with oropharyngeal dysphagia and a neck mass that varies in size depending on fluid/food intake
Zenker's diverticulum
| - MC type; in upper third of esophagus
231
cause of Zenkers
failure of cricopharyngeal mm to relax during swallowing leading to increased intraluminal pressure and outpouching of mucosa through weakened muscle
232
traction diverticula
midpoint of esophagus; caused by contiguous mediastinal inflammation and adenopathy that causes retraction of esophagus; no tx. required
233
epiphrenic diverticula
lower third of esophagus due to spastic esophageal dysmotility or achalasia
234
diagnostic test for diverticula in esophagus
barium swallow
235
intermittent dysphagia for solids only
lower esophageal ring
236
progressive dysphagia for solids only
can be either peptic stricture or cancer
237
intermittent dysphagia for solids and liquids with chest pain
diffuse esophageal spasm
238
Hamman's sign
mediastinal crunch - heart beating against air filled tissues in esophageal rupture
239
diagnostic study for ruptured esophagus
contrast esophagram with soluble Gastrograffin swallow
240
tx for esophageal rupture
surgery within 24 hours greatly improves survival
241
most accurate/preferred test for diagnosing ulcers
endoscopy
242
gold standard for dx. H.pylori
endoscopic biopsy
243
when is the urea-breath test ok to you for dx of h.pylori?
documents active infection
| assesses results of antibiotic therapy
244
what are the three tests that can test for h.pylori?
biopsy
urea-breath test - most convenient
serology - ab's can remain elevated longer after eradication
245
triple therapy for h.pylori
PPI, amoxicillin and clarithromycin
| - 10 days to 2 weeks
246
what drug can be used to reduce risk for ulcer formation associated with NSAID therapy
misoprostol
247
what kind of therapy is pretty much essential in pts with duodenal ulcers?
triple therapy for h.pylori
248
how long should a pt with PUD take anti-secretory drugs for?
4-6 weeks if uncomplicated ulcers and patient is asymptomatic; if pt is at risk for recurrence, consider maintenance therapy
249
how do you diagnose gastric outlet obstruction?
saline load test - empty stomach with NG tube, infuse 750 ml of saline, wait 30 min and aspirate; positive if > 400 ml aspirated
250
MCC of gastric outlet obstruction
```
duodenal ulcers
type III (prepyloric) gastric ulcers
```
251
how do you diagnose perforation of ulcer?
upright CXR shows free air under diaphragm
| CT scan is the most sensitive test for perforation
252
best test for evaluating pt with epigastric pain
upper endoscopy
253
pt presents with severe hemorrhagic gastric lesions after exposure of gastric mucosa to injurious agents such as NSAIDS and alcohol
acute erosive gastritis
254
what test is used to dx gastric cancer and what test is used for staging?
dx - endoscopy w/ multiple biopsies
| stage - CT scan
255
5 sites of mets from gastric cancer
```
Krukenberg - ovary
Virchow's node - supraclavicular
Irish's node - left axillary node
Blumer's shelf - pelvic cul de sac (rectum)
Sister Mary Joseph - periumbilical node
```
256
how can you clinically tell apart a proximal vs. distal small bowel obstruction?
proximal has lots of vomiting and severe pain whereas distal obstruction has significant abdominal distention
257
acid-base disorder in small bowel obstruction
hypochloremic, hypokalemia, metabolic alkalosis
258
what are the indications for surgery in bowel obstruction?
complete obstruction
partial obstruction that is persistent or assoc. with constant pain
strangulation if suspected
259
abdominal films show a uniform distribution of gas in the small bowel, colon and rectum
paralytic ileus
260
failure to pass contrast medium beyond a fixed point
paralytic ileus
261
Tx of paralytic ileus
usually resolves with time or when the cause is addressed medically
- surgery is not usually needed
262
Tx. algorithm for Crohn's disease
1. 5-ASA - esp. useful if colon involved
2. metronidazole - if 5ASA doesnt work
3. steroids - acute exacerbations/ if metro doesnt work
4. immunosuppressants (azathioprine) - with steroids
5. surgery - for complications
263
Drugs that cause esophagitis
Antibiotics: Tetracyclines
Anti-inflammatory : Aspirin and NSAIDs
Bisphosphonates: Alendronate
Other: KCl, quinidine, Iron
