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Flashcards in Gastrointestinal Step Up Deck (263):
1

what do you do if a patient has a positive FOBT? even if they are asymptomatic?

colonscopy

2

most sensitive and specific test for colon cancer

colonscopy

3

what test is complementary to flexible sigmoidoscopy in evaluating CRC?

barium enema

4

what is CEA useful for?

NOT SCREENING
- used for baseline and recurrence surveillance

5

what pre-op value of CEA implies worse prognosis in CRC?

> 5 ng/mL

6

what type of polyps have the highest malignant potential?

villous adenomas (Vs. tubular adenomas)

7

polyps plus osteomas, dental abnormalities, benign soft tissue tumors, desmoid tumors and/or sebaceous cysts

Gardner's syndrome
- risk of CRC is 100% by age 40

8

polyps plus cerebellar medulloblastoma or glioblastoma multiforme

Turcot's syndrome

9

multiple hamartomas throughout entire GI tract and pigmented spots around oral mucosa, lips and genitalia

Peutz-Jegher's syndrome

10

Lynch syndrome I

site specific CRC - early onset CRC

11

Amsterdam Criteria I

for dx. Lynch syndrome
- atleast 3 relatives with CRC (one first degree)
- 2+ generations
- one onset before age 50
- FAP has been excluded

12

Lynch syndrome II

early onset CRC plus other cancers (breast, endometrial ca, skin, stomach, pancreas, brain etc)

13

MCC of large bowel obstruction in adults

CRC

14

MC presenting symptom in CRC

abdominal pain

15

pt suspected of having CRC presents with anemia, weakness, occult blood in stool, melena, and iron deficiency anemia - where is the tumor likely located?

right sided tumors i.e. cecum
- lack of obstructive symptoms

16

pt suspected of having CRC presents with alternating constipation and diarrhea; he also has hematochezia - where is the tumor likely located?

left sided tumor

17

MC symptoms of rectal cancer

hematochezia with tenesmus and incomplete feeling of evacuation due to rectal mass

18

in what case of CRC is radiation therapy indicated?

rectal cancer

19

follow-up of CRC after resection includes? (4)

1. stool guaic test
2. annual CT scan of abdo/pelvis and CXR for 5 years
3. colonscopy at 1 year and then every 3 years
4. CEA levels

20

MC non-neoplastic polyps

hyperplastic (metaplastic) polyps
- commonly removed even though they are benign

21

MC type of neoplastic polyp

tubular adenoma

22

at what size is there greater risk of malignant potential in a colon polyp?

> 2.5 cm

23

what shape of polyp is most likely to be malignant

sessile (vs. pedunculated)

24

MC location of diverticulosis

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

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Tx. of diffuse esophageal spasm

antispasmolytics - nitrates and CCBs
TCAs - may provide sx relief

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which type of esophageal hiatal hernias are benign and associated with GERD?

sliding hernia

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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

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complications of sliding hiatal hernias

GERD
aspiration
esophagitis

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complications of paraesophageal hernias

strangulation
obstruction
hemorrhage

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Tx. of sliding hiatal hernia

medical - anatacids, small meals, elevation of head when sleeping
surgery - Nissen's fundoplication

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Tx. of paraesophageal hernia

elective surgery to prevent complications

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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

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first step in Mallory-Weiss syndrome?

upper endoscopy - diagnostic

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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

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pt presents with dysphagia, glossitis and iron deficiency anemia?

Plummer-Vinson syndrome - upper esophageal webs

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what are patients with Plummer-Vinson syndrome at risk for?

SCC of oral cavity, hypopharynx and esophagus

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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

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pt presents with dysphagia, regurgitation, bad breath and chronic cough - what can you suspect?

Esophageal diverticulum

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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

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cause of Zenkers

failure of cricopharyngeal mm to relax during swallowing leading to increased intraluminal pressure and outpouching of mucosa through weakened muscle

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traction diverticula

midpoint of esophagus; caused by contiguous mediastinal inflammation and adenopathy that causes retraction of esophagus; no tx. required

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epiphrenic diverticula

lower third of esophagus due to spastic esophageal dysmotility or achalasia

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diagnostic test for diverticula in esophagus

barium swallow

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intermittent dysphagia for solids only

lower esophageal ring

236

progressive dysphagia for solids only

can be either peptic stricture or cancer

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intermittent dysphagia for solids and liquids with chest pain

diffuse esophageal spasm

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Hamman's sign

mediastinal crunch - heart beating against air filled tissues in esophageal rupture

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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

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gold standard for dx. H.pylori

endoscopic biopsy

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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

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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

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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

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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

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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

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Drugs that cause esophagitis

Antibiotics: Tetracyclines
Anti-inflammatory : Aspirin and NSAIDs
Bisphosphonates: Alendronate
Other: KCl, quinidine, Iron