GI 1 pt 2

Question 1

Describe S/Sx of Conjugated hyperbilirubinemia (direct)

Answer 1

1) Possibly asymptomatic (mild)
2) Often with pruritis, light-colored stools (acholic), & jaundice
3) Malaise, anorexia, RUQ discomfort frequent with HC disease
4) Dark urine, jaundice, and in women, amenorrhea can occur
5) Other possible signs: enlarged tender liver, spider telangiectasias (angiomas), palmar erythema, ascites, gynecomastia, sparse body hair, fetor hepaticus, & asterixis

Question 2

Hyperbilirubinemia initial labs & imaging: What are the first labs you should order?

Answer 2

Sr total & unconjugated bilirubin, ALP, ALT & AST, PT/INR, albumin

Question 3

Hyperbilirubinemia initial labs & imaging:
1) What does it tell you if ALP, AST, & ALT are normal?
2) What abt if it’s predominant ALP elevation?
3) What if there’s a predominant AST & ALT elevation?

Answer 3

1) Not likely hepatic injury or biliary tract disease
2) Suggests biliary obstruction or intrahepatic cholestasis
3) Suggests jaundice caused by intrinsic hepatocellular disease

Question 4

1) What does elevated INR that corrects with Vit. K suggest?
2) What if elevated INR does not correct with Vit. K?

Answer 4

1) Suggests obstructive jaundice
2) Suggests hepatocellular disease with impaired synthetic function

Question 5

Hyperbilirubinemia initial labs & imaging: What are the 3 initial imaging options?

Answer 5

US, CT, MRI

Question 6

List some potential causes of abd. pain

Answer 6

1) Parietal peritoneal inflammation from bacterial contamination, chemical irritation
2) Mech. obstruction of hollow viscera
3) Vasc. disturbances
4) Distention of viscera
5) Inflammation

Question 7

True or false: IBS Sx can mimic ovarian CA

Answer 7

True

Question 8

List some potential causes of referred abd pain

Answer 8

1) Cardiothoracic
2) Metabolic causes
3) Neurologic
4) Toxins
5) Other

Question 9

Give some DDxs for abd. pain for each location:
1) Upper right quadrant
2) Epigastric
3) Left upper quadrant

Answer 9

Question 10

Give some DDxs for abd. pain for each location:
1) Right lower quadrant
2) Periumbilical
3) Left lower quadrant

Answer 10

Question 11

Give some potential causes of diffuse nonlocalized pain

Answer 11

1) Gastroenteritis
2) Mesenteric ischemia
3) Bowel obstruction
4) IBS
5) Peritonitis
6) Diabetes
7) Malaria
8) Metabolic diseases
9) Psych. disease

Question 12

Describe the patterns of referred abd pain

Answer 12

Question 13

GERD (non cardiac chest pain):
1) What can it mimic?
2) When may it occur?
3) How is it managed?

Answer 13

1) Angina pectoris with substernal squeezing or burning.
2) After meals, awaken patients from sleep, and be exacerbated by emotional stress
3) Acid suppressive therapy (usually PPIs x 4 weeks)

Question 14

Non-reflux esophagitis (medications, infections, radiation injury):
1) How does it present?
2) How is it managed?

Answer 14

1) Sternal chest pain, odynophagia
2) Address underlying etiology

Question 15

Eosinophilic esophagitis (EoE; non card. chest pain):
1) Epidemiology and etiology?
2) Sx?
3) How is it Dx’d?
4) How is it managed?

Answer 15

1) M>F, 20-30 y/o; strong association with food & environmental allergies, asthma, atopic dermatitis
2) Dysphagiawith solids, food impaction, central chest pain, refractory heartburn
3) Sx, endoscopic findings, & histology
4) Dietary modification (SFED,) PPIs, topical glucocorticoids, endoscopic dilatation of strictures, dupilumab (inhibits IL 4 &13)

Question 16

Esophageal motility disorder (non card. chest pain):
1) Sx?
2) Mgmt?

Answer 16

1) Squeezing retrosternal pain or spasm
Dysphagia with solids and liquids
2) Treat underlying etiology

Question 17

3 most common causes of infectious esophagitis are what?

Answer 17

1) Esophageal candidiasis
2) Herpes simplex virus (HSV)
3) Cytomegalovirus (CMV)

Question 18

Esophagitis via esophageal candidiasis:
1) What 2 conditions is it most common in?
2) What may they have simultaneously?
3) What is the hallmark Sx?
4) What is seen on endoscopy?

Answer 18

1) HIV & hematologic malignancies
2) May have concomitant thrush (oral candidiasis)
3) Hallmark symptom is odynophagia (pain in retrosternal area)
4) White mucosal plaque-like lesions on endoscopy
Biopsy shows yeast & pseudohyphae

Question 19

Esophagitis via esophageal candidiasis:
1) What would a culture show?
2) How do you manage this?

Answer 19

1) Candida spp
2) PO or IV antifungal (ie, fluconazole) x 14-21 days

Question 20

Esophagitis via HSV
1) Who is it common in?
2) What type of HSV is most common?
3) What may occur during primary HSV infection?
4) What 2 Sx do pts usually present with?

Answer 20

1) Immunocompromised (chemotherapy, transplantation, HIV)
2) Most commonly HSV type 1
3) Reactivation of HSV
4) Odynophagia and/or dysphagia

Question 21

Esophagitis via HIV:
1) What are 2 possible Sxs?
2) What is the Dx?
3) How is it managed?

Answer 21

1) Fever & retrosternal chest pain
2) Usually via endoscopic visualization confirmed by Bx
3) Acyclovir 400 mg PO 5 times daily x 14-21 days (immunocompromised)

Question 22

Esophagitis via CMV:
1) What is it an uncommon but serious complication of?
2) When is there a significant decrease in incidence?
3) In what setting does it mostly occur in?
4) Who is it most common in?

Answer 22

1) AIDS
2) Anti-Retroviral Therapy (ART)
3) Advanced immunosuppression (CD4 counts <50)
4) Patients not taking ART

Question 23

Esophagitis via CMV: Describe the clinical features

Answer 23

1) Odynophagia, nausea, substernal burning pain
2) Commonly causes multiple ulcers at the lower esophageal sphincter
3) May cause diffuse esophagitis

Question 24

List 2 reasons to endoscopy pts with CMV esophagitis

Answer 24

1) Endoscopy with biopsy for failure of empiric therapy (fluconazole for suspected Candida esophagitis)
2) Endoscopy for initial evaluation of severely symptomatic patients requiring hospitalization

Question 25

CMV esophagitis: 1) What will be seen in mucosal biopsies? 2) Are CMV in blood, tissue, or antibody indicated for diagnosis in AIDS?

Answer 25

1) Characteristic cytomegalic cells 2) No; does not reliably confirm or exclude end-organ disease

Question 26

Describe CMV esophagitis management

Answer 26

1) All should receive anti-CMV therapy 2) Start induction antiviral agent (ie, ganciclovir) inj x 3-6 weeks or until asymptomatic 3) IV therapy for severe disease 4) Initiate ART 5) Maintenance therapy: patients with concurrent CMV retinitis & those who relapse after induction therapy (usually with oral valganciclovir)

Question 27

Medication/Pill-Induced esophagitis: 1) What is it? Where does it usually occur? 2) What is the most common site for it to occur? Why? 3) What does this type of esophagitis cause?

Answer 27

1) Direct esophageal mucosal injury caused by medications; at anatomical sites of esophageal narrowing 2) Near level of aortic arch; extrinsic compression 3) Physiologic reduction in amplitude of esophageal peristaltic wave

Question 28

Medication/Pill-Induced esophagitis; give examples of the following etiologies: 1) Abx 2) Aspirin & anti-inflammatories 3) Biphosphates 4) Others

Answer 28

1) Tetracycline, doxycycline & clindamycin (direct irritant effect) 2) Aspirin & anti-inflammatories: ASA, NSAIDs (severe 3) Risedronate, alendronate (esophagitis, ulcers, strictures) 4) Potassium chloride, quinidine preparations, iron compounds, emepronium, alprenolol, pinavarium

Question 29

Medication/Pill-Induced esophagitis: List the clinical features

Answer 29

1) Retrosternal pain or heartburn 2) Odynophagia 3) Dysphagia 4) Rare (hematemesis, abdominal pain, weight loss) 5) Occurs within a few hours to 1 month after ingestion 6) Common history: swallowing pill without water, commonly at bedtime

Question 30

Medication/Pill-Induced esophagitis: How is it managed?

Answer 30

1) Discontinue culprit medication -If unable to discontinue, switch to liquid formulation 2) Consider antacids, PPIs, H2RAs, sucralfate 3) Consider short-term parenteral hydration or alimentation for patients with severe odynophagia with inability to eat or drink 4) Endoscopic dilation possibly needed in patients with esophageal stricture

Question 31

Esophageal dysmotility: 1) Define GERD 2) Define achalasia

Answer 31

1) Underlying hypotensive/incompetent LES 2) Tight stricture of inferior esophagus

Question 32

Esophageal dysmotility: achalasia: 1) What kind of dysphagia? 2) What Sx can it cause? 3) What exacerbates it? 4) How is it managed?

Answer 32

1) Dysphagia for solids & liquids 2) Regurgitation of food (undigested, non-acidic, non-bilious); Chest pain -“Bird beak” distal esophagus on barium-esophagram, dilated upper esophagus 3) Emotional stress & hurried eating 4) Pharmacologic, dilation of LES, surgical or endoscopic myotomy, botulinum toxin injection therapy

Question 33

Lower esophageal spasm (esophageal dysmotility): 1) What is it? 2) What are some main Sx? 3) What can it mimic? 4) What should be done to rule out common disorders?

Answer 33

1) Non-peristaltic contractions with normal LES relaxation 2) Chest pain, dysphagia with solids & liquids, regurgitation 3) Cardiac angina 4) EGD with biopsies

Question 34

Lower esophageal spasm (esophageal dysmotility): How is it managed?

Answer 34

1) Reassurance, PPIs, nitrates & CCBs, low-dose TCAs 2) Peppermint oil (Altoid mints) for dysphagia and/or chest pain in patients with no GERD (or well-controlled GERD)

Question 35

Hypercontractile esophagus (esophageal dysmotility): 1) What is it also called? 2) What does it cause? 3) What can rule out common disorders?

Answer 35

1) Aka Jackhammer esophagus, Nutcracker esophagus 2) Dysphagia with solids & liquids, +/- retrosternal chest pain +/- heartburn & regurgitation 3) EGD with biopsies

Question 36

Hypercontractile esophagus (esophageal dysmotility): How is it managed?

Answer 36

1) Management = nitrates or CCB 2) Low-dose TCAs for chest pain 3) Cognitive behavioral therapy 4) Peppermint oil for dysphagia and/or chest pain in patients with no GERD (or well-controlled GERD)

Question 37

What are some etiologic considerations for dysphagia?

Answer 37

1) Determine acuity (acute onset suggests impaction) 2) Distinguish from odynophagia (pain with swallowing) 3) Not related to rumination or globus sensation 4) Determine phase: oral, oropharyngeal, or esophageal

Question 38

Define dysphagia

Answer 38

Subjective sensation of difficulty swallowing

Question 39

List 3 tests for dysphagia and why you'd order each

Answer 39

1) **Pre-endoscopic or barium study**1 -History/clinical features of proximal esophageal lesion -Known complex (tortuous) stricture 2) **Upper endoscopy/EGD:** determine underlying cause, r/o malignancy, perform therapy 3) **Esophageal manometry:** upper endoscopy unrevealed or suspect motility disorder

Question 40

Esophageal obstruction: 1) What etiological consideration should you determine? 2) What are the Sx?

Answer 40

1) Food impaction vs non-food objects/foreign body 2) Choking, refusal to eat, hypersalivation, retrosternal fullness, regurgitation, wheezing, blood-stained saliva, odynophagia

Question 41

Esophageal obstruction: What is the diagnostic and therapeutic approach?

Answer 41

1) Upper endoscopy a) Remove obstruction (usually meat) b) Push food into stomach if able

Question 42

Barrett's esophagus: 1) Define 2) Pathogenesis? 3) Clinical features?

Answer 42

1) Replacement of the normal stratified squamous epithelium of the distal esophagus with metaplastic columnar epithelium (gastric & intestinal features) 2) Increased exposure & longer periods of acid reflux 3) No specific symptoms

Question 43

Barrett's esophagus: 1) How is it managed? 2) What abt for pts w. dysplasia?

Answer 43

1) Once daily PPI (even without symptoms of GERD) 2) Endoscopic eradication therapy and/or endoscopic resection

Question 44

Gastroesophageal reflux disease (GERD): 1) What is it? 2) What are 2 main causes? Describe each

Answer 44

1) Reflux of stomach contents into esophagus leading to pain/burning and/or complications 2) a) Physiologic (postprandial, short-lived, may be asymptomatic, rarely nocturnal) b) Pathologic (symptomatic or mucosal injury, often nocturnal)

Question 45

GERD: List some other misc. Sx

Answer 45

Dysphagia, chest pain, water brash, globus sensation (feeling of lump in the throat from spasm of upper esoph sphincter), odynophagia, extraesophageal symptoms (chronic cough, hoarseness, wheezing), & nausea

Question 46

Gastroesophageal reflux disease (GERD): 1) Classification? 2) Epidemiology? 3) Pathogenesis?

Answer 46

1) Erosive esophagitis or non-erosive reflux disease 2) Prevalence up to 20% in U.S., <5% in Asia 3) Transient relaxation of the lower esophageal sphincter

Question 47

List + describe the classic Sx of GERD

Answer 47

1) Heartburn (pyrosis): retrosternal burning sensation (usually postprandial) -Troublesome if mild symptoms > 2 days/week or moderate-severe symptoms > 1 day/week 2) Regurgitation: perceived gastric contents refluxed into mouth or hypopharynx

Question 48

GERD: 1) What will you see on PE? 2) How is it diagnosed? What should you test for? 3) What are some alarm features?

Answer 48

1) normal in uncomplicated disease 2) Clinical (must have classic symptoms) Testing if there are alarm features (upper GI series, EGD, Bravo pH) or failure of PPI therapy 3) Hematemesis/coffe-ground emesis, melena, wt loss, odynophagia or dysphagia.

Question 49

Describe the initial mgmt of GERD

Answer 49

Based on a) Frequency & severity of symptoms and b) Presence of erosive esophagitis or Barrett’s on endoscopy 1) Lifestyle & dietary modifications for all 2) Antacids, H2-blockers, and/or PPIs

Question 50

List some lifestyle modifications for GERD

Answer 50

1) Weight loss 2) Elevate head of bed 3) Eliminate dietary triggers (caffeine, chocolate, spicy foods, citrus, high-fat or fried foods, carbonated drinks, and alcohol) 4) Avoid tight-fitting clothing 5) Give Oral lozenges/chewing gum 6) Avoid tobacco & alcohol

Question 51

List the first, second, and third line Txs for GERD. What 2 things should you avoid?

Answer 51

1) 1st line: lifestyle & dietary modification 2) 2nd line: antacids followed by sucralfate -Avoid sodium bicarbonate & magnesium trisilicate (Gaviscon) 3) 3rd line: H2RAs followed by PPIs

Question 52

When do you do an EGD (upper endoscopy) for GERD?

Answer 52

Only if strong indication (ie, significant GI bleeding)

Question 53

True or false: You should do empiric acid suppression for patients with GERD, even if EGD indicated

Answer 53

True

Question 54

What are 3 referral criteria for GERD?

Answer 54

1) Failure of once daily PPI therapy (refractory GERD) 2) Intolerant to long-term PPIs 3) Desire to discontinue therapy

Question 55

Mallory-Weiss Tear: 1) What is it? What is the usual cause? 2) What is this tear a cause of? 3) What do lacerations often lead to?

Answer 55

1) Longitudinal mucosal lacerations (intramural dissection) in the distal esophagus and proximal stomach, which are usually associated with forceful retching 2) Upper GI bleeding 3) Lacerations often lead to bleeding from submucosal arteries

Question 56

What are some possible risk factors for Mallory-Weiss Tears?

Answer 56

1) Heavy alcohol use: bleeding usually worse when associated with portal hypertension & esophageal varices 2) Hiatal hernia 3) Age: unclear, as most MWT occur in patients under 40

Question 57

What are some precipitating factors for Mallory-Weiss tears?

Answer 57

Vomiting, straining or lifting, seizures, blunt abdominal trauma and nasogastric (NG) tube placement

Question 58

What are some clinical features of Mallory-Weiss tears?

Answer 58

1) Acute onset of hematemesis coffee-ground emesis 2) May have epigastric or back pain 3) May have history of non-bloody emesis, prolonged retching or coughing prior to onset 4) If significant bleeding, may have signs of hypovolemia & hemodynamic instability (resting tachycardia, hypotension) (typically pts with MW are pretty stable tho)

Question 59

Mallory-Weiss tear: 1) DDxs? 2) Dx?

Answer 59

1) Reflux esophagitis, medication-induced esophagitis, infectious esophagitis 2) Via upper endoscopy (EGD); also rules out other etiologies

Question 60

Define dyspepsia

Answer 60

Acute, chronic, or recurrent predominant epigastric pain/discomfort for at least 1 month

Question 61

List a bunch of etiologies of dyspepsia

Answer 61

1) Food intolerance (overeating, excess alcohol or coffee) 2) Drug intolerance (ASA, NSAIDs, antibiotics, DM drugs, ACE-I, SSRIs, steroids, iron, opioids) 3) Functional dyspepsia (FD): no organic etiology found 4) Peptic Ulcer Disease (PUD): 5-15% 5) GERD: up to 20% 6) Gastric or esophageal cancer: <1% 7) Gastroparesis 8) Parasitic infection: Giardia 9) Helicobacter pylori infection (+ PUD) 10) Pancreatic carcinoma & chronic pancreatitis 11) Biliary tract disease 12) Others (DM, thyroid, CKD, cardiac, malignancy, hernia, intestinal ischemia, pregnancy)

Question 62

Dyspepsia: 1) What should you do for alarm features? 2) What cause is common in young pts with multiple complaints, h/o anxiety or depression, h/o psychotropic meds? 3) What is rarely helpful?

Answer 62

1) Endoscopy or abdominal CT for alarm features 2) FD (functional dyspepsia) 3) Physical exam

Question 63

Dyspepsia: 1) What tests should you do for >/= 60? 2) What abt <60? 3) What is the study of choice to diagnose gastroduodenal ulcers, erosive esophagitis, & upper GI malignancy?

Answer 63

1) CBC, CMP (liver, calcium), thyroid function, EGD 2) Test for H. pylori first (urea breath test, fecal antigen test) 3) EGD

Question 64

Dyspepsia: 1) When should you endoscopy? 2) What should you consider for refractory symptoms or progressive weight loss? 3) What should you do when pancreatic, biliary tract, vascular disease, or volvulus are suspected?

Answer 64

1) Pts <60 with prominent alarm features + pts ~45 with higher incidence of gastric cancer 2) Celiac Ab, stool testing (O&Px3, Giardia), or fecal fat (elastase) 3) Abdominal US or CT

Question 65

Dyspepsia: 1) When should you empirically Tx? 2) What are other pharmacologic agents?

Answer 65

1) Pts <60 without alarm features; general treatment measures 2) Nortriptyline, buspirone, metoclopramide, prucalopride

Question 66

Helicobacter pylori induced injury: 1) What is it? 2) What is the etiology? 3) What causes the injury?

Answer 66

1) Direct alteration of signal transduction in mucosal and immune cells leading to increased acid secretion and diminished mucosal defenses 2) Noninvasive organism, but renders underlying mucosa vulnerable to acid damage Releases proteases that degrade the protective mucus 2) Host inflammatory/immune response

Question 67

NSAID induced injury: 1) How does this happen? 2) How much NSAID is needed to cause this? 3) What amount increases risk of duodenal ulcers?

Answer 67

1) Inhibits cyclo-oxygenase activity (COX-1 & COX-2) which impairs mucosal-protecting prostaglandin & nitric oxide leading to microscopic and macroscopic injury 2) As little as 10 mg ASA daily 3) 325 mg ASA QOD

Question 68

NSAID induced injury: 1) What is microscopic injury? 2) Give examples of macroscopic injury

Answer 68

1) Damage of surface cells by gastric acid 2) Edema, erythema, erosions, subepithelial hemorrhage, ulcers

Question 69

NSAID induced injury: 1) What may interact with H pylori and NSAIDs to increase mucosal injury? 2) When is there an increased risk of injury w NSAIDs? 3) NSAID-induced PUD _____________ with age

Answer 69

1) Cigarette smoking 2) Increased risk of injury within first 3 months (<1 week unlikely to cause injury in healthy adults) 3) increases

Question 70

NSAID induced injury: List some other misc risk factors

Answer 70

1) Dose of NSAID 2) H/o PUD 3) Comorbidities: disability (osteoarthritis), ASA/anticoagulant use, concurrent use of glucocorticoids & SSRIs

Question 71

Esophageal strictures: 1) What is it? 2) What are two different presentations?

Answer 71

1) Benign or cancerous narrowing or tightening of esophagus 2) Simple vs complex

Question 72

Esophageal strictures: Give examples of benign etiologies

Answer 72

1) Peptic stricture (more common) as complication of GERD (systemic sclerosis, NG tube) 2) Radiation therapy (thoracic or head/neck tumors) 3) Caustic ingestions, postsurgical resection, drug-induced, EoE

Question 73

Esophageal strictures: Give 2 examples of cancerous etiologies

Answer 73

1) Adenocarcinoma 2) SCC/ Squamous cell carcinoma

Question 74

Describe benign esophageal strictures

Answer 74

Usually short & contiguous with gastroesophageal junction; possible solid food dysphagia with progressive symptoms & episodic food impaction; management with endoscopic dilation & acid-suppressive therapy (PPIs)

Question 75

Describe cancerous esophageal strictures

Answer 75

Stricture indicates advanced lesion; rapidly progressing dysphagia (solids, then liquids); may have chest pain, odynophagia, anemia, anorexia, weight loss; management depends on staging

Question 76

Esophageal varices: 1) What is it? When is it most common? 2) How do pts present? 3) What is the prognosis?

Answer 76

1) Dilated veins due to portal hypertension; in setting of cirrhosis 2) W. hematemesis and/or melena 3) 15% of those who bleed from varices will die from the bleed

Question 77

Esophageal varices: 1) Is primary prophylaxis recommended? 2) What can Tx bleeding? What is the ultimate Tx?

Answer 77

1) Primary prophylaxis (prevention of 1st bleeding episode) is recommended with β-blocker 2) Bleeding is treated with rubber banding, sclerotherapy; transjugular intrahepatic portosystemic shunt (TIPS)

Question 78

Esophageal varices: variceal hemorrhage: 1) Why do they develop? 2) Where is the thinnest layer of supporting tissue and most likely to rupture & bleed? 3) What result in large increase in wall tension?

Answer 78

1) To decompress the hypertensive portal vein & return blood to systemic circulation 2) Gastroesophageal junction 3) Small increases in vessel radius

Question 79

Esophageal varices variceal hemorrhage 1) Why does Dx & management differ from other forms of GI bleeding? 2) There's a poor prognosis; why?

Answer 79

1) Different underlying cause (increased pressure gradient vs AVM, vs mucosal injury) 2) High rates of rebleeding, even in patients with spontaneous resolution (70% will rebleed over long term)

Question 80

Describe esophageal varices management

Answer 80

1) Hemodynamic resuscitation 2) Airway protection 3) Address coagulopathies 4) IV octreotide or somatostatin 5) Endoscopic variceal ligation; or endoscopic sclerotherapy 6) Balloon tamponade for continued bleeding 7) Trans-jugular intrahepatic portosystemic shunt (TIPS) -90-100% patients achieve hemostasis following TIPS

Question 81

90-100% of esophageal varices patients achieve hemostasis following _____________

Answer 81

Trans-jugular intrahepatic portosystemic shunt (TIPS)