GI Flashcards
(432 cards)
1
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GI
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Oral naloxegol is a peripherally acting μ-opioid receptor antagonist that is FDA-approved for the treatment of opioid-induced constipation in adults with chronic noncancer pain.
2
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he patient has hepatitis B virus (HBV) infection in the immune-tolerant phase, which can be determined by the likely vertical transmission and the patient’s young age, positive hepatitis B e antigen (HBeAg), high viral load, and normal aminotransferase levels.
Patients with hepatitis B infection in the immune-tolerant phase require serial monitoring of aminotransferase levels.
Patients with HBV infection in the immune-active, HBeAg-positive and reactivation, HBeAg-negative phases require treatment if the alanine aminotransferase level is elevated.
3
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Patients with HBV infection are at increased risk for hepatocellular carcinoma, even in the absence of cirrhosis. Patients from Southeast Asia should undergo hepatocellular carcinoma surveillance with ultrasonography starting at age 40 years for men and at age 50 years for women, and patients from sub-Saharan Africa should begin at age 20 years.
4
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Aspirin for secondary prophylaxis in patients with established cardiovascular disease should be continued after colonoscopy with polypectomy.
5
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Nonalcoholic fatty liver disease is the most common cause of abnormal liver test results in the United States.
The finding of a hyperechoic liver on ultrasonography is also consistent with NAFLD.
6
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The diagnosis of primary biliary cholangitis (PBC) is generally made on the basis of a cholestatic liver enzyme profile in the setting of a positive antimitochondrial antibody test
Autoimmune hepatitis is typically accompanied by higher autoantibody titers positive anti–smooth muscle antibody test
7
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Pseudoachalasia is caused by a tumor at the gastroesophageal junction infiltrating the myenteric plexus causing esophageal motor abnormalities; symptoms, barium-imaging and manometric findings, and endoscopic appearance are similar to achalasia.
Typical achalasia has an insidious onset and long duration of symptoms, often measured in years, before patients seek medical attention.
8
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A low-FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, And Polyols) diet can reduce abdominal pain and bloating and improve stool consistency, frequency, and urgency in patients with diarrhea-predominant irritable bowel syndrome.
Linaclotide is a peripherally acting guanylate cyclase-C activator approved by the FDA for the treatment of IBS-C
9
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GI
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Patients with dysphagia associated with regurgitation of undigested food should be evaluated with a barium esophagram for the presence of a Zenker diverticulum.
Treatment is reserved for symptomatic patients and endoscopic diverticulectomy is favored where surgical expertise is available.
10
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Esophageal manometry is used when there is concern for a motility disorder, such as achalasia. Patients with motility disorders commonly report dysphagia to liquids or both solids and liquids; this patient’s dysphagia to solid food does not suggest a motility disorder.
11
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Hepatopulmonary syndrome is a complication of cirrhosis caused by dilation of the pulmonary vasculature in the setting of advanced liver disease and portal hypertension. A high alveolar-arterial oxygen gradient results from functional shunting. Patients with hepatopulmonary syndrome usually have a preexisting diagnosis of liver disease and present with shortness of breath
The diagnosis of hepatopulmonary syndrome is made by demonstrating an arterial oxygen tension less than 80 mm Hg (10.7 kPa) breathing ambient air, or an alveolar-arterial gradient of 15 mm Hg (2 kPa) or greater, along with evidence of intrapulmonary shunting on echocardiography with agitated saline or macroaggregated albumin study.
12
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Cholecystectomy is the definitive treatment for acalculous cholecystitis in stable patients. However, this patient is now hemodynamically unstable and, therefore, requires a temporizing cholecystostomy tube to allow time for her to stabilize and for gallbladder inflammation to improve before cholecystectomy.
A hepatobiliary iminodiacetic acid scan may be used when ultrasonography is equivocal, and it would show nonopacification of the gallbladder in cases of cholecystitis.
13
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In patients requiring NSAIDs, an evidence-based treatment strategy to prevent recurrent NSAID-induced peptic ulcers is the use of a cyclooxygenase-2 selective NSAID plus a proton pump inhibitor.
14
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Patients with small (<10 mm) hyperplastic polyps on baseline colonoscopic examination should undergo surveillance colonoscopy in 10 years.
Sessile serrated polyps (also known as sessile serrated adenomas) and traditional serrated adenomas are both neoplastic and are precursors to colorectal cancer; they should be completely excised.
guidelines recommend managing large (>10 mm) hyperplastic polyps as if they are sessile serrated polyps.
15
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A 3-year surveillance interval is recommended for patients who have three or more adenomas (or sessile serrated polyps) found on baseline colonoscopy, one adenoma larger than 10 mm in size, or an adenoma with any degree of villous or high-grade dysplasia.
A surveillance interval of 5 years is recommended for patients with two or fewer adenomas (or sessile serrated polyps) found on baseline colonoscopy and for patients with a first-degree relative with colon cancer diagnosed at an age younger than 60 years.
16
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Patients who have cholangitis with evidence of biliary obstruction should be treated with antibiotic therapy and biliary decompression with endoscopic retrograde cholangiopancreatography.
In patients with evidence of biliary obstruction (as seen in this patient’s findings on ultrasonography) and more than mild disease, biliary decompression with ERCP is an essential component of therapy
Obstruction is typically indicated by a dilated bile duct and persistently elevated liver enzyme levels.
17
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Esophageal stricture in patients with eosinophilic esophagitis requires treatment with endoscopic dilation when symptoms do not respond to medical therapy.
Endoscopy with dilation is the most appropriate treatment for this patient, who has eosinophilic esophagitis, refractory symptoms of dysphagia despite fluticasone therapy, and the finding of an esophageal stricture on endoscopy
18
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Microscopic colitis is a cause of nonbloody, watery diarrhea in older adults and is diagnosed by colonoscopy with random biopsies from multiple colonic segments
Microscopic colitis is more common in older persons and does not cause endoscopically visible inflammation..
Microscopic colitis is associated with other autoimmune diseases such as diabetes mellitus and psoriasis
19
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GI
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Small intestinal bacterial overgrowth (SIBO) causes diarrhea, often with bloating, flatulence, and weight loss. Several conditions can predispose patients to SIBO due to effects on stomach acid, intestinal transit, or disruption of normal antibacterial defense mechanisms. Gastric bypass surgery is an increasingly common cause of SIBO. The absence of malabsorption symptoms and weight loss make this diagnosis unlikely.
20
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GI
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Almost all patients (>90%) with autoimmune pancreatitis enter clinical remission in response to glucocorticoids.
Based on his typical symptom of painless jaundice and the characteristic “sausage-shaped” pancreas on imaging, the patient has type 1 autoimmune pancreatitis, a frequent manifestation of IgG4 disease
Endoscopic retrograde cholangiopancreatography with bile-duct stenting is usually not required in patients with autoimmune pancreatitis because most patients’ symptoms respond quickly to oral prednisone
21
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GI
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The fetus should be delivered immediately upon recognition of acute fatty liver of pregnancy.
Women with acute fatty liver of pregnancy typically present with a 1- to 2-week history of nausea and vomiting, right-upper-quadrant or epigastric pain, headache, jaundice, anorexia, and/or polyuria and polydipsia.
22
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The finding of a gallbladder polyp larger than 1 cm in size, or a polyp of any size associated with gallstones, is an indication for cholecystectomy even if the patient is asymptomatic.
Cholecystectomy is indicated for this patient with a gallbladder polyp and gallstones because of the increased risk for gallbladder cancer when the two conditions coexist.
In a patient with an 8-mm gallbladder polyp in the absence of gallstones or primary sclerosing cholangitis, repeat ultrasonography in 6 months would be indicated.
23
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GI
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After eradication therapy for Helicobacter pylori infection, eradication should be confirmed using the urea breath test or fecal antigen test.
Testing to confirm eradication should be pursued in all cases of identified and treated Helicobacter pylori infection because of the established risks for peptic ulcer disease and gastric malignancy in patients with chronic H. pylori infection
Unless upper endoscopy is indicated for other reasons, noninvasive testing modalities (the urea breath test or the fecal antigen test) are more appropriate for confirmation of eradication or assessment for reinfection.
24
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Same-admission cholecystectomy reduces rates of gallstone-related complications compared with cholecystectomy after hospital discharge for patients with mild gallstone pancreatitis.
25
GI
Indications for endoscopic retrograde cholangiopancreatography in patients with primary sclerosing cholangitis are bacterial cholangitis, increasing jaundice, increasing pruritus, or a dominant stricture on imaging.
Symptoms of bacterial cholangitis, increasing jaundice, and pruritus can signify strictures that may improve with dilation or stenting, or, alternatively, removing sludge or stone debris in the bile ducts via ERCP
26
GI
IgG4 levels should be checked in patients with a new diagnosis of presumed PSC because IgG4 cholangitis is a steroid-responsive condition, whereas PSC is not.
27
GI
Red-flag symptoms such as rectal bleeding with iron deficiency anemia, abdominal pain, and weight loss should prompt evaluation by colonoscopy for colorectal cancer regardless of the patient's age or the presence of bleeding hemorrhoids.
28
GI
Narcotic bowel syndrome, also known as opiate-induced gastrointestinal hyperalgesia, is a centrally mediated disorder of gastrointestinal pain characterized by a paradoxical increase in abdominal pain with increasing doses of opioids.
29
GI
Treatment of chronic pancreatitis–related persistent pain should proceed in a stepwise approach beginning with lifestyle modifications (discontinue alcohol and cigarettes) and the use of simple analgesics (acetaminophen, NSAIDs).
30
GI
Sofosbuvir and ledipasvir are direct-acting antiviral agents used to treat hepatitis C virus (HCV) infection and would be an appropriate choice for mild HCV-related PAN.
Mild hepatitis B virus–related polyarteritis nodosa is treated with antiviral agents like entecavir.
31
GI
Enteral nutrition is preferred in patients with acute pancreatitis because of the benefit of maintaining a healthy gut mucosal barrier to prevent translocation of bacteria.
Total parenteral nutrition (TPN) is discouraged in patients with acute pancreatitis because the mucosal barrier is not maintained when patients are NPO for prolonged periods, which may lead to higher rates of bacterial translocation into necrotic pancreatic tissu
32
GI
Primary prophylactic antibiotic therapy is indicated for patients at high risk for the development of spontaneous bacterial peritonitis, including patients with very low ascitic-fluid protein levels and those with advanced liver failure.
Criteria for patients at high risk include an ascitic-fluid total protein level less than 1.5 g/dL (15 g/L) in conjunction with any of the following: serum sodium level less than or equal to 130 mEq/L (130 mmol/L), serum creatinine level greater than or equal to 1.2 mg/dL (106.1 µmol/L), blood urea nitrogen level greater than or equal to 25 mg/dL (8.9 mmol/L), serum bilirubin level greater than or equal to 3 mg/dL (51.3 µmol/L), or Child-Turcotte-Pugh class B or C cirrhosis.
33
GI
Rapid gastric emptying of hyperosmolar chyme into the small intestine after partial gastric resection can lead to postprandial vasomotor symptoms, abdominal pain, and diarrhea, collectively known as dumping syndrome.
Common early symptoms of dumping symptoms are palpitations, tachycardia, diaphoresis, and lightheadedness with abdominal pain and diarrhea presenting within 30 minutes of eating.
Small intestinal bacterial overgrowth (SIBO) is an excess number and alteration in type of bacteria cultured from the small intestine. Unlike in dumping syndrome, symptoms are not immediately related to eating and are not associated with prominent vasomotor symptoms such as palpitations, tachycardia, diaphoresis, and lightheadedness.
34
GI
Linaclotide is a peripherally acting guanylate cyclase-C receptor agonist that is FDA approved for the treatment of chronic idiopathic constipation in adults with symptoms refractory to first-line therapies.
Osmotic laxatives include magnesium hydroxide, lactulose, sorbitol, and polyethylene glycol (PEG); clinical trials have demonstrated the superiority and safety of PEG.
35
GI
Pregnant women who have hepatitis B virus DNA levels greater than 200,000 IU/mL at 24 to 28 weeks' gestation should be treated with tenofovir to prevent vertical transmission during delivery.
Guidelines recommend treatment with lamivudine, telbivudine, or tenofovir for the prevention of vertical transmission in pregnant women who have HBV DNA levels greater than 200,000 IU/mL at 24 to 28 weeks' gestatio
36
GI
Once endoscopic hemostasis has been achieved in a patient with gastrointestinal bleeding, anticoagulation should be reinitiated, and in most cases, this can be done on the same day as the procedure.
37
GI
Anti–tissue transglutaminase IgA antibody testing is the best screening test for celiac disease.
38
GI
After treatment of colon cancer, patients should undergo surveillance colonoscopy 1 year after diagnosis.
If the colonoscopy is normal, the AGA recommends repeat examination in 3 years; ASCO recommends repeat examination in 5 years. If normal, colonoscopy should be repeated every 5 years thereafter until the benefit of continued surveillance is outweighed by risks and diminished life expectancy.
If neoplasms are detected during any follow-up examination, then the surveillance interval should be adjusted based on polyp size, number, and histology
39
GI
Surgical resection is the best management option for high-risk cystic lesions of the pancreas, such as intraductal papillary mucinous neoplasms that involve the main duct.
40
GI
Angiography is used to diagnose the cause of obscure gastrointestinal bleeding when more common sources are not found on routine upper and lower endoscopy. It is also used for treatment, such as embolization, when a bleeding source has been identified.
41
GI
Secretory and osmotic diarrhea can often be distinguished by clinical history. Patients with secretory diarrhea may pass liters of stool daily, causing severe dehydration and electrolyte disturbances, with persistent stooling despite fasting. Patients with osmotic diarrhea often have stool volumes of less than 1 L/d and have cessation of stooling when they are fasting.
42
GI
Secretory and osmotic diarrhea can often be distinguished by clinical history. Patients with secretory diarrhea may pass liters of stool daily, causing severe dehydration and electrolyte disturbances, with persistent stooling despite fasting. Patients with osmotic diarrhea often have stool volumes of less than 1 L/d and have cessation of stooling when they are fasting.
43
GI
Colonoscopy results in Crohn disease show patchy distribution of mucosal inflammatory changes with “skip areas” of normal intervening mucosa, and biopsy results for involved mucosa show features of chronicity (distorted and branching colonic crypts).
Because ulcerative colitis typically involves the rectum, tenesmus, urgency, rectal pain, and fecal incontinence are common. Patients with ulcerative colitis have distorted and branching colonic crypts on biopsy, but the distribution of inflammation begins in the rectum and progresses up the colon in a continuous and symmetric pattern, without skip areas.
44
GI
Patients with uncomplicated diverticulitis should undergo colonoscopy 1 to 2 months after the episode of acute diverticulitis, when colonic inflammation has resolved.
45
GI
Patients with newly diagnosed pernicious anemia should be evaluated for gastric adenocarcinoma and gastric carcinoid with upper endoscopy and gastric biopsy.
46
GI
Anal fissures are tears in the anoderm below the dentate line that can be seen on inspection of the perianal area, often unaided by the use of an anoscope.
The most effective treatment approach for anal fissure is daily warm-water sitz baths and the use of the bulk laxative psyllium.
47
GI
Patients with multiple fundic gland polyps found at a young age should be evaluated for familial adenomatous polyposis.
Colonoscopy to rule out FAP is recommended in patients younger than age 40 years with dysplastic or numerous fundic gland polyps.
48
GI
Approximately 5% of patients with inflammatory bowel disease will develop primary sclerosing cholangitis during the course of their disease, typically presenting as cholestatic liver injury with a characteristic imaging study showing bile duct strictures and dilations (“string of beads”).
In most patients, PSC presents as a stricturing process in the medium to large bile ducts, readily identifiable by MR cholangiopancreatography
49
GI
Patients with a clinical diagnosis of gastroesophageal reflux disease should start an empiric trial of a proton pump inhibitor in conjunction with lifestyle and dietary changes, with no further testing.
Upper endoscopy is indicated in patients with alarm symptoms, such as dysphagia or weight loss, and in patients whose symptoms do not respond to a PPI.
50
GI
All hospitalized patients with inflammatory bowel disease should be given pharmacologic venous thromboembolism prophylaxis with subcutaneous heparin.
51
GI
Ambulatory pH testing can be a helpful diagnostic test in patients with suspected extraesophageal manifestations of gastroesophageal reflux disease.
extraesophageal symptoms of GERD include asthma, globus sensation, hoarseness, throat clearing, and chronic laryngitis. It appears that the laryngopharynx is more sensitive to the erosive effects of acid, and small amounts of reflux may produce symptoms. The selection of a diagnostic test to confirm or exclude laryngopharyngeal reflux is controversial. Ambulatory pH testing, if positive, can help to confirm the diagnosis of GERD and supports the diagnosis of laryngopharyngeal reflux. Negative ambulatory pH testing suggests that the patient does not have GERD and that proton pump inhibitor therapy should be discontinued
52
Medications that decrease kidney perfusion, including NSAIDs, ACE inhibitors, and angiotensin receptor blockers, should be discontinued in patients with ascites.
53
Acute liver failure is an indication for immediate referral to a liver transplantation center.
Acute liver failure is defined by the manifestation of hepatic encephalopathy within 26 weeks of developing symptoms of liver disease. The development of jaundice was this patient's first symptom of liver disease. Within 6 weeks, he developed coagulopathy, with an INR of 2.6, as well as symptoms of hepatic encephalopathy (confusion and asterixis).
54
GI
Combined mesalamine therapy (oral and topical) is superior for induction of remission in mild to moderately active ulcerative colitis compared with oral or topical therapies alone.
. The distribution of ulcerative colitis is generally divided into proctitis (involving the rectum only), left-sided colitis (inflammation does not extend beyond the splenic flexure), and pancolitis (inflammation extends above the splenic flexure).
55
Patients younger than age 60 years presenting with dyspepsia should first undergo a noninvasive test for Helicobacter pylori followed by eradication therapy if testing is positive.
Upper endoscopy should be performed routinely in patients older than age 60 years with persistent dyspeptic symptoms. Clinicians may treat a minority of patients older than age 60 years with empirical therapy instead of endoscopy, provided the risk of upper gastroenterologic malignancy is low.
56
GI
The mainstay of therapy for amebic liver abscesses is antibiotic therapy, such as metronidazole, plus a luminal agent, such as paromomycin, to eradicate the coexisting intestinal infection.
57
GI
Chronic bloody diarrhea and abdominal discomfort are typical presenting symptoms of inflammatory bowel disease; endoscopic findings help distinguish ulcerative colitis from Crohn disease.
The endoscopic description of inflammation beginning at the anorectal verge and extending proximally in a continuous fashion with transition to normal mucosa at splenic flexure is consistent with left-sided ulcerative colitis.
Crohn disease characteristically has a patchy progression pattern resulting in “skip lesions” and may spare the rectum, making Crohn colitis less likely in this case.
58
GI
Wilson disease should be considered in all patients younger than age 40 years who have unexplained liver disease.
hen Wilson disease causes acute hepatitis, usually in young patients, the sudden release of copper from liver cells can also induce hemolytic anemia. In this patient with evidence of hepatic encephalopathy, hemolytic anemia, low alkaline phosphatase level, and unconjugated bilirubinemia, the diagnosis of Wilson disease should be considered. The serum ceruloplasmin level is used to test for Wilson disease.
59
The clinical presentation of achalasia consists of dysphagia to both solids and liquids.
Patients with achalasia who are at high surgical risk should be treated with endoscopic botulinum toxin injection.
Pneumatic dilation is the most effective nonsurgical treatment and is more cost-effective than surgical myotomy, but it is associated with serious complications, such as esophageal perforation. Therefore, patients who are not surgical candidates should not undergo endoscopic dilation treatment of achalasia.
60
GI
In patients with atypical chest pain, a cardiac cause must be ruled out before starting treatment for gastroesophageal reflux disease.
61
GI
The relapsing, remitting variant of hepatitis A viral infection is characterized by multiple clinical or biochemical relapses with spontaneous improvement within months to 1 year without intervention.
62
GI+.
Long-term proton pump inhibitor (PPI) therapy for uncomplicated gastroesophageal reflux disease should be given at the lowest effective dose possible, and consideration should be given to reducing or stopping PPI therapy at least once a year.
Maintenance PPI therapy is recommended for patients with GERD who continue to have symptoms after the initial course of a PPI is discontinued, and for those who have erosive esophagitis or Barrett esophagus.
63
GI
The mainstay of therapy for intrahepatic cholestasis of pregnancy is ursodeoxycholic acid, which is associated with alleviated symptoms and improved liver test abnormalities.
64
GI
Isolated right-colon ischemia may be a warning sign of acute mesenteric ischemia caused by embolism or thrombosis of the superior mesenteric artery and should be evaluated using CT angiography.
65
GI
Olmesartan causes medication-induced enteropathy that can mimic refractory celiac disease.
In 2013, the FDA issued a warning that olmesartan medoxomil can cause intestinal symptoms known as sprue-like enteropathy and approved labeling changes to include this concern. The enteropathy may develop months to years after starting olmesartan. Drug-associated enteropathy can mimic refractory celiac disease with findings of villous atrophy and increased intraepithelial lymphocytes in the first part of the duodenum.
66
GI
Endoscopic ablation should be considered after confirmation of dysplasia by a second expert pathologist.
67
GI
Barrett esophagus with low-grade dysplasia should be treated with endoscopic ablation therapy in patients without significant comorbidities.
In the past, guidelines recommended a surveillance endoscopy in 6 months for patients with low-grade dysplasia. However, more recent guidelines recommend that patients with minimal comorbidities undergo endoscopic ablation therapy for permanent eradication of Barrett esophagus
68
GI
Giardia lamblia infection is a common parasitic infection that occurs most often among children, child care workers, and backpackers or campers who drink untreated water from lakes, rivers, or wells. Treatment options include tinidazole, metronidazole, and nitazoxanide.
A 24-hour 5-hydroxyindoleacetic acid measurement is used to evaluate for carcinoid tumors. Up to 85% of patients with gastrointestinal carcinoid syndrome experience intermittent flushing. In addition to flushing, diarrhea is prominent in most patients and is related to rapid intestinal transit time.
69
GI
The diagnosis of gastroparesis requires the presence of specific symptoms, absence of mechanical outlet obstruction, and objective evidence of delay in gastric emptying into the duodenum.
70
GI
The mainstay of therapy for variceal hemorrhage is endoscopic therapy, and adjunctive therapies such as antibiotic therapy improve outcomes.
he mainstay of therapy for variceal hemorrhage is endoscopic therapy. Antibiotic therapy is an important adjunctive therapy for variceal bleeding because bacterial infection occurs in 30% to 40% of patients within 1 week of variceal bleeding
71
GI
Individuals with a first-degree relative with colon cancer or an advanced adenoma diagnosed at an age younger than 60 years, or two or more first-degree relatives with colon cancer or advanced adenoma diagnosed at any age, should begin colon cancer screening at age 40 years (or 10 years earlier than the youngest age at which colon cancer was diagnosed in a first-degree relative, whichever is first).
72
GI
Patients with cirrhosis and who meet the Milan criteria (up to three hepatocellular carcinoma tumors ≤3 cm or one tumor ≤5 cm) are best treated with liver transplantation and have excellent 5-year survival rates.
73
GI
A diagnosis of hepatocellular carcinoma can be made in a patient with cirrhosis in the presence of lesions larger than 1 cm that enhance in the arterial phase and have washout of contrast in the venous phase.
Biopsy of the lesion is not indicated in this patient. In the context of cirrhosis, a lesion larger than 1 cm with contrast enhancement in the arterial phase and portal venous washout meets radiologic criteria for hepatocellular carcinoma and, therefore, does not require a lesion biopsy.
74
GI
Eosinophilic esophagitis typically presents in young men with symptoms of dysphagia and in patients with a history of food allergies, eczema, and asthma.
Pill-induced esophagitis has been observed with medications including alendronate, quinidine, tetracycline, doxycycline, potassium chloride, ferrous sulfate, and mexiletine.
75
GI
Incidentally found gallstones with no associated symptoms and no complications require no further intervention.
76
GI
the classic “herald bleed” of aortoenteric fistula: a brisk bleed associated with hypotension that stops spontaneously and then is followed later by massive gastrointestinal hemorrhage. An aortoenteric fistula is a communication between the aorta and the gastrointestinal tract, most commonly located in the distal duodenum, especially the third portion, because the duodenum is fixed and located just anterior to the aorta. The possibility of an aortoenteric fistula must be considered in a patient with previous aortic graft surgery who presents with gastrointestinal bleeding.
77
GI
Patients with uncomplicated diverticulitis should be treated conservatively with oral antibiotics.
Physical examination findings include fever, left-lower-quadrant tenderness, and/or a lower abdominal or rectal mass. If clinical features are highly suggestive of diverticulitis, imaging studies are unnecessary. If the diagnosis is not clear or if an abscess is suspected (severe pain, high fever, palpable mass), CT imaging is indicated
intravenous antibiotics are appropriate in patients who cannot take oral medications or who have complicated diverticulitis, such as abscess or fistula formation
78
gi
Fecal loading (excess stool in the colon) with resultant overflow diarrhea is a common cause of fecal incontinence in elderly patients, particularly those who are hospitalized or have degenerative neurologic disorders.
Before treating the diarrhea, it is essential to determine whether the diarrhea is due to overflow from fecal loading (excess stool in the colon). An abdominal radiograph is a simple, safe, and inexpensive diagnostic test
79
GI
Ischemic colitis is a low-flow state of the colon occurring most frequently in the left colon and characterized by moderate, left-sided, cramping abdominal pain followed by bloody diarrhea.
80
GI
Anti–tumor necrosis factor agents such as infliximab are effective in inducing and maintaining remission in moderate to severe Crohn disease.
81
GI
Patients with Lynch syndrome should begin screening colonoscopy between ages 20 and 25 years or 2 to 5 years before the earliest age of colorectal cancer diagnosis in the family, whichever comes first, and colonoscopy should be repeated every 1 to 2 years if the baseline examination is normal.
82
GI
A history of multiple family members with gastric cancer, particularly before age 50 years, or multiple family members with lobular breast cancer with or without gastric cancer, suggest the possibility of hereditary diffuse gastric cancer and the need for upper endoscopy and testing for mutations of the CDH1 gene.
83
GI
In patients with well-preserved liver function, drug-induced liver injury should be managed with discontinuation of the offending medication and observation until resolution of symptoms occurs.
84
GI
Upper-endoscopy screening for duodenal cancer in patients with familial adenomatous polyposis should begin at onset of colonic polyposis or at age 25 to 30 years, whichever comes first.
85
GI
The presence of three or more adenomas, any adenoma greater than or equal to 1 cm in size, or any adenoma with villous features or high-grade dysplasia has been associated with increased risk for metachronous neoplasia (multiple primary tumors developing at different time intervals), warranting a 3-year surveillance interval.
85
GI
The presence of three or more adenomas, any adenoma greater than or equal to 1 cm in size, or any adenoma with villous features or high-grade dysplasia has been associated with increased risk for metachronous neoplasia (multiple primary tumors developing at different time intervals), warranting a 3-year surveillance interval.
86
GI
Mixed cryoglobulinemia arising from chronic hepatitis C viral infection resolves after treatment and eradication of the virus.
Other direct-acting antiviral agents that could be used interchangeably to treat genotype 1 HCV include grazoprevir-elbasvir; paritaprevir-ritonavir, ombitasvir, and dasabuvir; glecaprevir-pibrentasvir; sofosbuvir-daclatasvir; and sofosbuvir-velpatasvir.
87
The first step in the management of microscopic colitis is to discontinue a potentially causative medication, after which supportive treatment with antidiarrheal agents such loperamide can be tried, with budesonide recommended for patients whose symptoms do not respond.
88
GI
For women with asymptomatic hepatic adenomas smaller than 5 cm in size, estrogen-containing oral contraceptive agents should be discontinued, and follow-up liver imaging is recommended every 6 months for at least 2 years.
89
GI
Capsule endoscopy is the most appropriate test to evaluate patients for causes of small-bowel bleeding after negative upper endoscopy and colonoscopy.
90
GI
Chronic hepatitis B viral infection in the immune-active, hepatitis B e antigen–positive phase should be treated with tenofovir or entecavir to decrease hepatic inflammation and the risk for progression to fibrosis.
91
GI
For Helicobacter pylori infection that persists after eradication therapy, the salvage therapy regimen should consist of different antibiotics from those used in the initial, unsuccessful regimen.
92
GI
In patients with end-stage liver disease and portal hypertension, hepatorenal syndrome is characterized by the development of oliguric kidney failure, bland urine sediment, and marked sodium retention (edema, ascites, low urinary sodium).
93
GI
Asymptomatic patients with walled-off necrosis of the pancreas require no intervention.
94
GI
Patients with hepatitis C viral infection who achieve sustained virologic response have a reduced risk for hepatocellular carcinoma; regardless of virologic response, ultrasonographic surveillance is recommended for patients with stage 3 or stage 4 fibrosis.
95
In a patient with suspected Achalasia, dysphagia for solids and liquids and regurgitation of
undigested food, what is the first test in evaluation?
barium esophagography; shows “bird's beak” narrowing of the GE junction
96
In a patient with suspected Achalasia, dysphagia for solids and liquids and regurgitation of
undigested food, after barium esophagropahy is done, what is the next test in evaluation?
upper endoscopy to rule out adenocarcinoma (pseudoachalasia) at the GE
junction
97
In a patient with suspected Achalasia, dysphagia for solids and liquids and regurgitation of
undigested food, what text confirms diagnosis? ?
esophageal manometry confirms diagnosis by documenting absence of peristalsis and incomplete relaxation of the LES with swallows
98
If the patient has a history of travel to South America and with suspected Achalasia, dysphagia for solids and liquids and regurgitation of
undigested food, what diagnosis should be suspected?
If the patient has a history of travel to South America, suspect Chagas disease as
the cause of achalasia.
99
Which clinical syndrome is associated with this pic?
The “bird's beak” finding reflects narrowing of the distal esophagus and is
characteristic of achalasia.
100
What is the first-line therapy for achalasia?
Laparoscopic myotomy of the LES is the first-line therapy for achalasia.
101
If a patient has Less than X number of days of watery diarrhea they require no testing or
microscopic assessment?
Healthy patients with watery diarrhea of less than 3 days' duration require no testing or
microscopic assessment.
102
After how long should watery diarrhea be evaluated with stool testing?
If diarrhea does not resolve in 1 week, evaluation is
recommended with stool testing for common bacterial pathogens and toxins, including
Clostridioides difficile.
103
Under what scenarios should pts have diagnostic
assessment of their stool to guide antimicrobial use?
Patients with mucoid or bloody diarrhea (dysentery), fever, or suspected sepsis and
those who are immunocompromised or require hospitalization should have diagnostic
assessment of their stool to guide antimicrobial use.
104
which GI infection develops most often in patients with AIDS, but outbreaks also occur in immunocompetent patients, often related to public swimming pools?
Cryptosporidiosis
105
Which GI infection can mimic appendicitis or Crohn disease?
Yersinia enterocolitica colitis can mimic appendicitis or Crohn disease.
106
Patients with bloody diarrhea (dysentery) and temperatures >101 °F should be treated with empirically with what antibiotic after
microbiologic assessment?
Dysentery with temperatures >101 °F should be treated with empiric azithromycin (after
microbiologic assessment).
107
what is the Treatment for travel-associated diarrhea?
Treat travel-associated diarrhea with empiric azithromycin.
108
what is the tx for Diarrhea caused by parasites (Giardia lamblia or Entamoeba histolytica)?
Diarrhea caused by parasites (Giardia lamblia or Entamoeba histolytica) requires therapy
with metronidazole, tinidazole, or nitazoxanide.
109
Should you treat/choose antibiotics for EHEC colitis?
Do not choose antibiotics for EHEC colitis.
110
can you choose loperamide or diphenoxylate for acute diarrhea with fever or
blood in the stool?
NO! Do not choose loperamide or diphenoxylate for acute diarrhea with fever or
blood in the stool. Both agents are associated with HUS in EHEC colitis and toxic
megacolon in C. difficile infection.
111
Which clinical syndrome is associated with acute liver injury complicated by encephalopathy and
coagulopathy in patients without previous cirrhosis?
Acute liver failure refers to acute liver injury complicated by encephalopathy and
coagulopathy in patients without previous cirrhosis.
112
Which 4 drugs are most commonly associated with Drug-induced liver injury ?
Drug-induced liver injury is most commonly caused by acetaminophen, antibiotics
(particularly amoxicillin-clavulanate), and antiepileptic medications (phenytoin and
valproate).
113
What is the most common cause of acute liver failure?
Acetaminophen overdose, the most
common cause of acute liver failure
114
Which clinical syndrome is associated with Sudden elevation of serum AST and ALT levels
up to 20×?
Acetaminophen overdose
115
How is acetaminophen overdose managed?
Measure serum acetaminophen
level and use nomogram to
determine whether
N-acetylcysteine is indicated.
116
Which clinical syndrome is associated with Outbreaks of acute liver failure associated with
foods such as raspberries and scallions?
Acute HAV infection
117
Which clinical syndrome is associated with Acute elevation of AST to >1000 U/L while
hospitalized?
Episode of acute hypotension with
associated liver hypoperfusion
118
Which clinical syndrome is associated with Acute elevation of liver enzymes and hemolysis
in a young patient, Kayser-Fleischer rings,
history of psychiatric disorders, and/or
athetoid movements?
Wilson disease
119
How is Wilson disease managed?
Measure serum copper and
ceruloplasmin levels and urine
copper excretion.
120
Which clinical syndrome is associated with this pic?
Wilson disease. A Kayser-Fleischer ring in the cornea is bracketed with arrowheads.
121
What is the treatment For patients with acute liver failure?
For patients with acute liver failure, choose:
* immediate contact w/liver transplantation center
* N-acetylcysteine for confirmed or suspected acetaminophen poisoning
* lactulose for any degree of encephalopathy
122
In patients with acute liver failure and altered
mental status, what evaluation should be next?
Head CT should be performed in patients with acute liver failure and altered
mental status to rule out cerebral edema or intracranial hemorrhage.
123
What is the diagnostic criteria for pancreatitis?
Diagnosis of acute pancreatitis requires at least two of the following criteria:
* acute onset of upper abdominal pain
* serum amylase or lipase increased ≥3× ULN (lipase is more specific and sensitive
than amylase)
* findings suggesting pancreatitis on cross-sectional imaging (ultrasonography, CT, MRI)
124
What is the most common complication of acute pancreatitis.?
Pancreatic pseudocysts are the most common complication of acute pancreatitis.
125
All patients with acute pancreatitis require what before leaving the hospital?
All patients with acute pancreatitis require abdominal ultrasonography to evaluate the
biliary tract for obstruction.
126
when is CT of the abdomen is indicated for pancreatitis?
CT of the abdomen is indicated only if the pancreatitis is severe, it lasts longer than 48
hours, or complications are suspected.
127
Pertaining to pancreatitis, which findings are
worrisome for abscess, pseudocyst, or necrotizing pancreatitis?
Uncomplicated pancreatitis is not typically associated with rebound abdominal
tenderness, absent bowel sounds, high fever, or melena. When these findings are
present, consider abscess, pseudocyst, or necrotizing pancreatitis.
128
Besides pancreatitis, what else can Mildly increased amylase values represent?
Mildly increased amylase values can also be caused by kidney disease, intestinal
ischemia, appendicitis, and parotitis.
129
For treatment of pancreatitis, In addition to vigorous IV hydration and pain relief, when should oral feeding resume?
oral feeding when nausea, vomiting, and abdominal pain resolve
130
For treatment of pancreatitis, In addition to vigorous IV hydration and pain relief, when should enteral jejunal feedings start if oral feeding not tolerated?
enteral jejunal feedings within 72 hours if oral feeding not tolerated
131
For treatment of pancreatitis, In addition to vigorous IV hydration and pain relief, what else should be done for presentation for ascending cholangitis or biliary
obstruction?
ERCP within 24 hours of presentation for ascending cholangitis or biliary
obstruction
132
For pancreatitis, what time frame is fluids beneficial?
Fluid resuscitation (250-500 mL/h) is most beneficial in the first 12-24 hours and
may be detrimental after this therapeutic window.
133
When do Pancreatic pseudocysts require drainage ?
Pancreatic pseudocysts do not require drainage unless they cause significant
symptoms or are infected, regardless of size.
134
What is an important step in evaluation of patients with pancreatic necrosis?
surgical consultation for pancreatic necrosis
135
Which clinical syndrome is associated with jaundice, leukocytosis, and tender hepatomegaly, with or without fever, AST and ALT measurements <300 to 500 U/L, with an AST/ALT ratio >2.0?
Severe alcoholic steatohepatitis is called alcoholic hepatitis and is symptomatic.
136
When is Prednisolone indicated for
patients Alcoholic Hepatitis?
Prednisolone is indicated for
patients with a Maddrey Discriminant Function (MDF) score ≥32, Model for End-Stage
Liver Disease (MELD) score >20, or encephalopathy.
137
For alcoholic hepatitis, when should prednisolone should be discontinued for non improvement?
If the bilirubin level (or Lille score) does not improve by day 7, prednisolone should be
discontinued.
138
Should you use glucocorticoids in patients with alcoholic hepatitis ?
Do not use glucocorticoids in patients with alcoholic hepatitis and GI bleeding,
infection, pancreatitis, or kidney disease.
139
Which clinical syndrome is associated with elevation of aminotransferase levels, elevated IgG levels, positive ANA and anti–smooth muscle antibody titers, positive p-ANCA or anti-LKM I antibody?
Autoimmune Hepatitis
140
How is Autoimmune Hepatitis diagnosed?
Liver biopsy establishes the diagnosis.
141
What other conditions can be found in patients with autoimmune hepatitis?
Fifty percent of patients with autoimmune hepatitis have other autoimmune diseases,
such as thyroiditis, ulcerative colitis, or synovitis.
142
Which clinical syndrome is associated with High serum total protein and low serum albumin levels?
High serum total protein and low serum albumin levels suggest an elevated
serum γ-globulin level, which may be the only clue to hypergammaglobulinemia.
143
When should patients with autoimmune hepatitis be considered for treatment with glucocorticoids or Azathioprine?
Patients who have active inflammation on liver biopsy specimens or are symptomatic
should be considered for treatment with glucocorticoids and azathioprine. Relapse
144
What is the treatment for autoimmune hepatitis ?
autoimmune hepatitis be considered for treatment with glucocorticoids or Azathioprine?
145
Which clinical syndrome is associated with a narrowed main pancreatic duct or parenchymal
swelling (“sausage-shaped” pancreas) ?
Autoimmune Pancreatitis
146
In a patient with Autoimmune Pancreatitis, what other clinical condition should be excluded?
It is important to exclude pancreatic cancer; biopsy may be necessary.
147
Which type (type 1 autoimmune pancreatitis or type 2 AIP) is more likely seen with elevated IgG4-related diseases and other other IgG4-related
diseases, such as Sjögren syndrome, PSC, bile duct strictures?
Type 1 AIP is seen in older men and may be associated with other IgG4-related
diseases, such as Sjögren syndrome, PSC, bile duct strictures, autoimmune thyroiditis,
retroperitoneal fibrosis, sclerosing sialoadenitis, and interstitial nephritis. Serum IgG4
level is increased.
148
Which type (type 1 autoimmune pancreatitis or type 2 AIP) is more likely associated with chronic pancreatitis and IBD and is less likely to include
elevated IgG4 levels?
Type 2 AIP is associated with chronic pancreatitis and IBD and is less likely to include
elevated IgG4 levels.
149
What is the treatment for both type 1 and 2 Autoimmune Pancreatitis?
Most patients with type 1 or 2 AIP respond to glucocorticoids. Patients with relapsed
disease typically respond to glucocorticoid retreatment.
150
What age, demographic and comorbidity require screening for barretts esophagus?
Screen men aged >50 years with GERD symptoms for more than 5 years and additional risk factors (nocturnal reflux symptoms, hiatal hernia, elevated BMI, tobacco use, intra-abdominal distribution of fat) to detect BE.
151
How is Barretts esophagus diagnosed?
The diagnosis of BE is based on endoscopic tissue biopsy.
152
What is the Treatment for patients with BE without dysplasia?
Treat patients with BE without dysplasia with a PPI.
153
what is the treatment for patients with barretts with confirmed low- or high-grade dysplasia?
Endoscopic ablation or mucosal resection is recommended for patients with confirmed
low- or high-grade dysplasia.
154
In patients with BE and no dysplasia, how often should surveillance examinations occur?
In patients with BE and no dysplasia, surveillance examinations should occur at intervals
no more frequently than 3 to 5 years.
155
For patients with Barrets E and low-grade
dysplasia who do not choose endoscopic ablation, how often should surveillance examinations occur? .
More frequent intervals of 12 months are indicated in patients with BE and low-grade
dysplasia who do not choose endoscopic ablation.
156
Do Women with GERD require routine screening for Barretts?
Women with GERD do not require routine screening for BE.
157
Should you select antireflux surgery to prevent the progression of BE to
adenocarcinoma?
Do not select antireflux surgery to prevent the progression of BE to
adenocarcinoma.
158
Which clinical syndrome occurs secondary to ingestion of wheat gluten or related rye and barley
proteins in genetically predisposed persons?
Celiac Disease
159
what other autoimmune conditions are associated with celiac disease?
type 1 diabetes mellitus
* autoimmune thyroid disease
160
which cancer is associated with celiac disease?
small bowel lymphoma
161
How is celiac disease diagnosed?
Diagnostic tests include an IgA anti-tTG antibody assay with small bowel biopsy for
those with a positive antibody assay.
162
In testing for celiac disease, what is the next step diagnostic tests after someone has a positive IgA anti-tTG antibody assay?
small bowel biopsy
162
In testing for celiac disease, what is the next step diagnostic tests after someone has a positive IgA anti-tTG antibody assay?
small bowel biopsy
163
For patients with suspected celiac disease, and IgA
deficiency what additional step should be considered to make a diagnosis of celiac disease?
An association between celiac disease and IgA
deficiency may lead to false-negative IgA-based tests. In patients with IgA deficiency,
assays for IgG anti-tTG or IgG-deamidated gliadin peptides are necessary.
164
what should be measured in all patients with newly diagnosed celiac disease?
Measure bone mineral density in all patients with newly diagnosed celiac disease.
165
How can the effectiveness of diet therapy for celiac be determined?
by remeasuring IgA anti-tTG antibody
titers or repeating small bowel biopsies.
166
what is the most common reason for failure of a gluten-free diet?
Nonadherence is the most common reason for failure of a gluten-free diet.
167
for celiac patients who are adherent to gluten free diet, and have recurrent malabsorption, what should they be evaluated for next?
Adherent
patients with recurrent malabsorption should be evaluated for other conditions,
including microscopic colitis and intestinal lymphoma.
168
Which med may be added initially to hasten dermatitis herpetiformis associated wit celiac?
Dapsone may be added initially to hasten dermatitis herpetiformis symptom resolution.
.
169
before using Dapsone what should you check for?
Dapsone may be added initially to hasten dermatitis herpetiformis symptom resolution.
Before using dapsone, check for G6PD deficiency.
170
when treating constipation, after Increasing physical activity and dietary fiber, what is the first step in treatment?
Add soluble fibers, such as psyllium and methylcellulose.
171
When treating constipation, after Increasing physical activity and dietary fiber and after Adding soluble fibers, such as psyllium and methylcellulose, what is the next step to treat constipation?.
Add surfactants, such as docusate sodium or docusate calcium (appropriate for
very mild, intermittent constipation).
172
When treating constipation, after Increasing physical activity and dietary fiber and after Adding soluble fibers, such as psyllium and methylcellulose, and after adding surfactants, such as docusate sodium or docusate calcium, what is the next step to treat constipation?
Add osmotic laxatives, such as magnesium hydroxide, lactulose, sorbitol, and PEG
3350
173
When treating constipation, after Increasing physical activity and dietary fiber and after Adding soluble fibers, such as psyllium and methylcellulose, and after adding surfactants, such as docusate sodium or docusate calcium, and then osmotic laxatives, such as magnesium hydroxide, lactulose, sorbitol, and PEG
3350, what is the next step to treat constipation?
Add stimulant laxatives, such as anthraquinone, senna, and the
diphenylmethanes (fastest-acting agents).
174
If chronic constipation does not respond to initial stepped approach, what final agents can be used?
If chronic constipation does not respond to initial stepped approach, prosecretory agents (lubiprostone and linaclotide) can be used.
175
What clinical condition is associated with Chronic senna use can and benign pigmentation of the colon?
Chronic senna use can lead to benign pigmentation of the colon, known as
melanosis coli.
176
Which clinical syndrome is associated with this pic?
Melanosis coli
177
Which clinical syndrome is associated with abnormal brown or black pigmentation of the colonic mucosa and is frequently found in patients with long-term stimulant laxative use.?
Melanosis coli is an abnormal brown or black pigmentation of the colonic mucosa
and is frequently found in patients with long-term stimulant laxative use.
178
In order to be chronic, how long does diarrhea have to last?
Chronic diarrhea is defined as lasting at least 4 weeks.
179
which type of diarrhea is most commonly caused by lactase deficiency?
Osmotic diarrhea is most commonly caused by lactase deficiency. l.
180
What type of diarrhea is associated with
eating, improves with fasting, and is not nocturnal?
Osmotic diarrhea is associated with
eating, improves with fasting, and is not nocturnal.
181
which type of diarrhea is characterized by large-volume, watery, nocturnal bowel
movements and is unchanged by fasting?
Secretory diarrhea is characterized by large-volume, watery, nocturnal bowel
movements and is unchanged by fasting
182
for patients with chronic diarrhea what test should be selected?
Select colonoscopy for most patients with chronic diarrhea; biopsies of the colonic
mucosa should be performed to assess for microscopic colitis.
183
for patients with chronic diarrhea what test should be selected?
Select colonoscopy for most patients with chronic diarrhea; biopsies of the colonic
mucosa should be performed to assess for microscopic colitis.
184
For patients with chronic diarrhea and an elevated fecal calprotectin what dx should be considered?
IBD
185
For patients with chronic diarrhea and positive Stool or urine laxative screen what dx should be considered?
laxative abuse.
186
For patients with chronic diarrhea and A reduced fecal elastase level which dx should be considered?
A reduced fecal elastase level supports chronic pancreatitis.
187
For patients with chronic diarrhea and A positive 72-hour stool collection for fecal fat what dx should be considered?
A positive 72-hour stool collection for fecal fat confirms steatorrhea.
188
What are the four most common disorders causing steatorrhea?
The four most common disorders causing steatorrhea are:
* celiac disease
* SIBO
* short-bowel syndrome
* pancreatic insufficiency
189
An An osmotic gap GREATER THAN WHAT AMOUNT indicates osmotic diarrhea?
An osmotic gap >100 mOsm/kg H2O indicates osmotic diarrhea.
190
An An osmotic gap LESS THAN WHAT AMOUNT indicates SECRETORY diarrhea?
A gap <50 mOsm/kg H2O indicates secretory diarrhea.
191
How do you calculate the stool osmotic gap?
Stool electrolytes The osmotic gap is
calculated as 290 − (2 × [Na + K]).
192
which Stool electrolytes can be measured in liquid stool to calculate the fecal osmotic gap?
Stool electrolytes (sodium and potassium)
193
Which clinical syndrome is associated with Bloating, abdominal discomfort relieved by a bowel movement, no weight loss or alarm features ?
IBS; test for celiac disease
194
Which clinical syndrome is associated with Diarrhea mainly in women aged 45-60 years, nocturnal diarrhea, normal colonoscopy ?
Microscopic colitis; stop NSAIDs/PPIs; biopsy needed to confirm diagnosis
195
Which clinical syndrome is associated with Diarrhea with dairy products ?
Lactose intolerance; dietary exclusion or hydrogen breath test
196
Which clinical syndrome is associated with Use of artificial sweeteners or fructose ?
Carbohydrate intolerance; dietary exclusion or hydrogen breath
test
197
Which clinical syndrome is associated with Nocturnal diarrhea and diabetes mellitus or SSc ?
SIBO; hydrogen breath test or empiric antibiotic trial
198
Which clinical syndrome is associated with Coexistent pulmonary diseases and/or recurrent Giardia infection ?
CVID and selective IgA deficiency; measure immunoglobulins; consider CF
199
Which clinical syndrome is associated with Somatization or other psychiatric syndromes, history of
laxative use ?
Self-induced diarrhea; obtain tests for stool osmolality,
electrolytes, magnesium, and laxative screen
200
Which clinical syndrome is associated with diarrhea and exposure to young children or potentially contaminated water (lakes and streams). ?
Infection with G. lamblia should be considered in patients with exposure to
young children or potentially contaminated water (lakes and streams).
201
What is a common cause of Chronic Pancreatitis?
Alcohol use disorder is a common cause.
202
What associated conditions can result or be seen as a result of chronic pancreatitis?
* exocrine pancreatic insufficiency (steatorrhea, osteoporosis)
* exocrine pancreatic insufficiency (diabetes)
203
What on imaging suggests chronic pancreatitis?
pancreatic calcifications on imaging
204
In Young adults with chronic pancreatitis, what other test is required ?.
Young adults with chronic pancreatitis require sweat chloride testing for CF.
205
Chronic pancreatitis disease onset in older patients without risk factors requires exclusion of what 2 conditions?
autoimmune
pancreatitis (AIP) and pancreatic cancer.
206
do Normal amylase and lipase levels rule out chronic pancreatitis?
No
207
Do you need Pancreatic biopsy and endoscopic retrograde cholangiopancreatography to diagnosis chronic pancreatitis?
Pancreatic biopsy and endoscopic retrograde cholangiopancreatography are not
indicated in the diagnosis of chronic pancreatitis
208
Which clinical syndrome is associated with
Dyspnea, hypoxemia, increased A-a gradient; AND exhibit platypnea (increased dyspnea sitting up and decreased dyspnea lying flat)
Hepatopulmonary
syndrome
209
How is Hepatopulmonary syndrome diagnosed?
Confirm using transthoracic contrast echocardiography
210
In the setting of Cirrhosis which clinical syndorme is associated with Increase in serum creatinine of at least 0.3 mg/dL and/or ≥50% from baseline within 48 hours, bland urinalysis, and normal findings on kidney ultrasonography?
Hepatorenal
syndrome type 1
211
which syndrome (Hepatorenal syndrome type 1 vs 2) is less severe, with a more gradual decline in kidney function and association with diuretic-refractory ascites?
Hepatorenal
syndrome type 2
212
which clinical syndrome Encompasses osteoporosis, osteopenia, and rarely osteomalacia in the context of liver disease?
Hepatic
osteodystrophy
213
For new cirrhotic pts with ascites, what should be done to dx the cause of ascites?
paracentesis for newly discovered ascites and calculation of the serum-ascites
albumin gradient (SAAG) to diagnose the cause of ascites
214
paracentesis with ascitic fluid granulocyte count and culture for any change in
mental status or clinical condition to diagnose spontaneous bacterial peritonitis
215
what 3 screenings should be done for cirrhotic pts?
* upper endoscopy for all new patients to evaluate for varices
* ultrasonography to diagnose ascites Patients with cirrhosis should undergo ultrasonography screening for HCC every 6
months.
216
what does a SAAG greater than 1.1 indicate?
Right-sided HF, Budd-Chiari syndrome, Cirrhosis
216
what does a SAAG less than 1.1 indicate?
Malignancy, TB, Nephrotic syndrome
217
what Ascitic fluid granulocyte count confirms spontaneous bacterial peritonitis?
Ascitic fluid granulocyte count >250/μL confirms spontaneous bacterial peritonitis.
218
how often should Patients with cirrhosis have screening for HCC?
Patients with cirrhosis should undergo ultrasonography screening for HCC every 6
months.
219
should you obtain a Head CT in patients with hepatic encephalopathy and otherwise normal
neurologic examination?.
Head CT in patients with hepatic encephalopathy and otherwise normal
neurologic examination is not warranted.
220
In pts with with esophageal varices, should you use Use IV or oral, bisphosphonate therapy?
Use IV, not oral, bisphosphonate therapy in patients with esophageal varices.
221
what is the tx for Primary prophylaxis of variceal
bleeding?
First choice: propranolol, nadolol, or carvedilol
222
If β-blocker is not tolerated or contraindicated in prophylaxis of variceal bleeding, what is the second line choice fort tx?
Second choice: endoscopic band ligation if β-blocker not tolerated or contraindicated
223
For patients with Active variceal bleeding, what is the treatment?
Octreotide with endoscopic band ligation and prophylactic ciprofloxacin or ceftriaxone
224
at what level should you Transfusion for active variceal bleeding?
Hemoglobin transfusion goal 7 g/dL
225
what is the tx for Ascites not responding to low-
sodium diet?
Spironolactone with or without furosemide
226
what is the tx for Diuretic-refractory ascites?
Serial large-volume paracentesis (with albumin if >5 L), TIPS, or liver transplantation
227
When do you give albumin with Serial large-volume paracentesis?
Serial large-volume paracentesis (with albumin if >5 L)
228
if active variceal bleed, what is the tx for Prevention of spontaneous bacterial
peritonitis?
Ciprofloxacin or ceftriaxone for 7 days if active bleeding
229
what is the tx for Prevention of spontaneous bacterial peritonitis?
Fluoroquinolones chronically if history of spontaneous bacterial peritonitis or otherwise
high riska
Fluoroquinolones while hospitalized if ascitic fluid protein <1.5 g/dL
230
what is the tx for Acute hepatic encephalopathy ?
Correct precipitating factors, lactulose; add rifaximin if unresponsive
231
what is the tx for Prevention of hepatic
encephalopathy?
Lactulose, titrated to 3 stools per day
232
what is the tx for Hepatic osteodystrophy ?
Calcium, vitamin D, and IV bisphosphonate
233
In Hepatorenal syndrome should diuretics, be continued?
Stop diuretics, volume expansion with IV albumin; midodrine and octreotide or
norepinephrine may be helpful.
234
what is the definitive treatment for patients with end-stage or decompensated liver disease?
Liver transplantation is the definitive treatment for patients with end-stage or
decompensated liver disease.
235
Should you select prophylactic protein restriction to prevent hepatic encephalopathy?
no
236
should Antimicrobial prophylaxis be administered during variceal bleeding even
if ascites is absent?
Antimicrobial prophylaxis should be administered during variceal bleeding even
if ascites is absent.
237
which meds should be Stop in patients with ascites?
Stop ACE inhibitors, ARBs, and NSAIDs in patients with ascites.
238
Which clinical syndrome occurs within 30 minutes of eating, associated with palpitations, flushing or pallor, diaphoresis, lightheadedness, hypotension, diarrhea, nausea, abdominal bloating, cramping, and borborygmus?
Early dumping syndrome, can be a complications of bariatric surgery
239
what type of liver injury primarily results in elevated AST and ALT values?
Hepatocellular injury primarily results in elevated AST and ALT values.
240
Which clinical syndrome is associated with ALT values >5000 U/L?
ALT values >5000 U/L usually result from acetaminophen hepatotoxicity or
hepatic ischemia.
241
An AST/ALT ratio >2.0 suggests what condition?
An AST/ALT ratio >2.0 suggests alcoholic hepatitis.
242
which 2 classes of injury are associated with both aminotransferase elevations >1000 U/L (ALT > AST) and serum total bilirubin levels >15 mg/dL.?
Virus- or drug-induced acute hepatitis usually causes serum aminotransferase
elevations >1000 U/L (ALT > AST) and serum total bilirubin levels >15 mg/dL.
243
Abnormalities in which two labs, imply severe hepatocellular dysfunction?
Prolonged PT/INR and low serum albumin values imply severe hepatocellular
dysfunction.
244
What clincal condition is associated with minimal ALT and AST elevations in a patient with obesity, hyperlipidemia, and hypertension?
nonalcoholic liver disease.
245
which types of liver injury primarily cause elevated serum bilirubin and alkaline
phosphatase values with proportionally lesser elevations of aminotransferase levels?
Cholestatic liver diseases
246
What is required to establish the diagnosis of Gilbert syndrome?
Extensive testing is not required to establish the diagnosis of Gilbert syndrome;
verify normal aminotransferase levels and the absence of hemolysis.
247
how is the bilirubin pattern different (conj vs unconj) in ?
Overproduction (hemolysis) or impaired uptake (e.g., Gilbert syndrome) of bilirubin
is characterized by >80% indirect (unconjugated) bilirubin, whereas hepatocyte
dysfunction or impaired bile flow (obstruction) is characterized by >20% direct
(conjugated) bilirubin.
248
Which clinical syndrome is associated with an inflammatory response following microperforation of a diverticulum and is characterized by LLQ abdominal pain; fever may be present?
Diverticulitis
249
Which clinical syndrome is associated with rupture of an artery that has penetrated a diverticulum, is typically painless, and usually stops without therapy?
Diverticular bleeding
250
Which clinical syndrome is associated with Pneumaturia, fecaluria, or recurrent/polymicrobial UTI?
Pneumaturia, fecaluria, or recurrent/polymicrobial UTI suggests a diverticulitis-
related colovesical fistula.
251
If clinical features highly suggest diverticulitis, are imaging studies necessary?
If clinical features highly suggest diverticulitis, imaging studies are unnecessary.
252
For stable patients with diverticulitis, what is the tx?
For stable patients with diverticulitis, select a liquid diet and a 7- to 10-day course of
oral antibiotics, such as ciprofloxacin and metronidazole.
253
when should pts be Hospitalized for diverticulitis?
Hospitalize patients if they are unable to maintain oral intake for IV fluids and
antibiotics.
254
How does the management of small and large abscesses associated with diverticulitis differ?
A small abscess may resolve with antimicrobial therapy alone. CT-guided drainage can
facilitate nonsurgical management of larger abscesses.
255
When is Emergent surgery required for diverticulitis?
Emergent surgery is required when conservative treatment fails or for peritonitis, sepsis, or perforation.
256
What is recommended to prevent recurrent diverticulitis?
A high-fiber diet is recommended to prevent recurrent diverticulitis.
257
Should you perform colonoscopy in the setting of acute diverticulitis?
Avoid colonoscopy in the setting of acute diverticulitis; air insufflation may
increase the risk of perforation.
258
when should A colonoscopy should be performed following diverticulitis to rule out colon cancer?
A colonoscopy should be performed following recovery to rule out colon cancer.
259
What is the difference between oropharyngeal and esophageal dysphagia?
Oropharyngeal Dysphagia is associated with difficulty initiating swallowing, coughing, choking, and nasal regurgitation of fluids, muscular or neurologic disorders, most commonly stroke, Parkinson disease.
Esophageal Dysphagia is associated with
food “sticking” or discomfort in the retrosternal region, mechanical obstruction or a motility disorder
260
What is used to evaluate suspected oropharyngeal dysphagia?
Videofluoroscopy is used to evaluate suspected oropharyngeal dysphagia.
261
what type of abnormality is suggested by solid-food dysphagia?
Solid-food dysphagia suggests a structural esophageal abnormality.
262
what type of abnormality is suggested by solid-food and liquid dysphagia or liquid dysphagia?
Solid-food and liquid dysphagia or liquid dysphagia alone suggests an esophageal
motility abnormality, such as achalasia.
263
what type of abnormality is suggested by solid-food dysphagia that occurs episodically for years?
Solid-food dysphagia that occurs episodically for years suggests an esophageal web or
a distal esophageal ring (Schatzki ring).
264
what type of abnormality is suggested by progressively increasing solid-food dysphagia for several months ?
Progressively increasing solid-food dysphagia for several months suggests a peptic
stricture or carcinoma.
265
How is Oropharyngeal dysphagia managed?
Oropharyngeal dysphagia is managed with dietary adjustment and speech therapy.
266
what is the most common presenting symptom of esophagitis?
Odynophagia is the most common presenting symptom of esophagitis.
267
What is the most common infectious cause of esophagitis?
Candida albicans is the most common infectious cause, followed by CMV and HSV.
268
how should Patients with oral candidiasis and odynophagia be treated ?
Patients with oral candidiasis and odynophagia are treated empirically.
269
what is seen on upper endoscopy in pts with Candida ?
White mucosal plaque-like lesions consistent with Candida are seen on upper
endoscopy.
270
Which clinical syndrome is associated with this pic?
Esophageal Candida
271
which esophagitis is found in immunodeficient or immunosuppressed patients, and
ulcerative oropharyngeal lesions are rar
Viral esophagitis is found in immunodeficient or immunosuppressed patients, and
ulcerative oropharyngeal lesions are rare.
272
Which clinical syndrome is associated with Young adults with severe dysphagia and
food impaction and. Other atopic conditions, such as asthma, rhinitis, dermatitis, and
seasonal or food allergies,?
Young adults with eosinophilic esophagitis (EE) present with severe dysphagia and
food impaction. Other atopic conditions, such as asthma, rhinitis, dermatitis, and
seasonal or food allergies, are common.
273
If empiric therapy for esophagitis is
unsuccessful, what should be done next?
Perform upper endoscopy with biopsy/brushing if empiric therapy for esophagitis is
unsuccessful.
274
What does Upper endoscopy and biopsies show in patients with eosinophilic esophagitis?
Upper endoscopy in patients with EE may show mucosal furrowing, stacked circular
rings, white specks, and mucosal friability. Endoscopic biopsies show marked infiltration
with eosinophils.
275
Does the absence of oral Candida lesions rule out esophageal candidiasis?
The absence of oral Candida lesions does not rule out esophageal candidiasis.
276
what is the tx for eosinophilic esophagitis?
PPI, swallowed fluticasone, or budesonide for EE
277
what is the tx for for CMV esophagitis?
ganciclovir or valganciclovir for CMV esophagitis
278
what is the tx for HSV esophagitis?
acyclovir, famciclovir, or valacyclovir for HSV esophagitis
279
what is the tx for esophageal candidiasis?
fluconazole or itraconazole for esophageal candidiasis
280
Which clinical syndrome is characterized by the episodic onset of acute, severe, epigastric or RUQ pain lasting 30 minutes to 6 hours and often
accompanied by nausea and vomiting?
Biliary colic is characterized by the episodic onset of acute, severe, epigastric or RUQ pain lasting 30 minutes to 6 hours and often
accompanied by nausea and vomiting.
281
Which clinical syndrome is associated with fever, leukocytosis, and elevated liver enzymes?
Fever, leukocytosis, and elevated liver enzymes
indicate acute cholecystitis or obstruction of the common bile duct.
282
What is seen on US that indicates an obstructing stone?
Dilation of the cystic or biliary duct
indicates an obstructing stone.
283
what is the initial imaging modality for suspected Gallstones, Acute Cholecystitis, or
Cholangitis?
Ultrasonography is the initial imaging modality.
284
Which clinical syndrome is associated with Epigastric or RUQ pain, fever, bilirubin <4 mg/dL, normal or minimally elevated AST
or ALT, leukocytosis?
Acute cholecystitis
285
Which clinical syndrome is associated with ?
286
Which clinical syndrome is associated with ?
287
Which clinical syndrome is associated with ?
288
Which clinical syndrome is associated with Biliary colic or pancreatitis and no gallstones or bile duct dilation on imaging
studies?
Biliary crystals (sludge)
289
Which clinical syndrome is associated with RUQ pain, fever, jaundice, or these findings plus shock and mental status changes;
bilirubin >4 mg/dL; AST and ALT >1000 U/L?
Acute cholangitis
290
what is seen on US with Acute cholecystitis?
Sonogram shows thickened gallbladder wall and the presence of pericholecystic
fluid.
291
Which clinical syndrome is associated with Critically ill, febrile, or septic patient
No gallstones on sonogram, but findings otherwise compatible with acute
cholecystitis?
Acute acalculous cholecystitis
292
Which clinical syndrome is associated with ?
293
Which clinical syndrome is associated with RUQ pain, pelvic adnexal tenderness, leukocytosis, cervical smear showing
gonococci?
Fitz-Hugh–Curtis syndrome (gonococcal or
chlamydial perihepatitis)
294
Which clinical syndrome is associated with Impacted gallstone in cystic duct, jaundice, and dilated common hepatic duct
caused by extrinsic compression?
Mirizzi syndrome
295
Which clinical syndrome is associated with Biliary colic or cholecystitis with small-bowel obstruction and air in biliary tree?
Cholecystenteric fistula (gallstone ileus)
296
what is the tx for Biliary colic?
Elective cholecystectomy if gallstones are demonstrated on imaging
297
what is the tx for Acute cholecystitis?
β-lactam/β-lactamase inhibitor or r a third-generation cephalosporin plus metronidazole. Surgery before hospital discharge
298
what is the tx for Acute cholangitis ?
Antibiotic therapy same as for acute cholecystitis
ERCP removal of common bile duct stones
299
In a patient without alarm features (anemia, dysphagia, vomiting, weight loss), is EGD required?
In a patient without alarm features (anemia, dysphagia, vomiting, weight loss), symptom
relief with a PPI is both diagnostic and therapeutic.
300
what is the next step in pt with GERD symptoms refractory to empiric therapy with PPIs?
Upper endoscopy;
301
In a pt with GERD symptoms refractory to
empiric therapy with PPIs, the next step is EGD. What if the EGD is normal?
Upper endoscopy; if normal, then choose ambulatory esophageal pH monitoring or impedance
pH testing while taking a PPI for symptom–reflux correlation
302
in a pt with Dysphagia, odynophagia, and
weight loss what is the next step in evaluation?
Upper endoscopy to rule out cancer
303
what is the first-line therapy for GERD and GERD with extraesophageal manifestations
(asthma, laryngitis, cough)?
PPIs are first-line therapy for GERD and GERD with extraesophageal manifestations
(asthma, laryngitis, cough).
304
what is the tx for GERD In patients not responding to once- daily PPI treatment?
* In patients without alarm features, GERD management consists of once-daily PPI twice-daily PPI for 4-8 weeks is indicated in patients not responding to once-
daily treatment.
305
Which clinical syndrome is characterized by delayed gastric emptying with recurrent nausea, early satiety, bloating, and weight loss?
Gastroparesis
306
what are the 5 causes of Gastroparesis?
* systemic sclerosis
* diabetes mellitus
* hypothyroidism
* anticholinergic agents
* opioids
307
what clues suggest a viral cause of gastroparesis?
A viral cause is suggested by rapid onset of gastroparesis after a presumed viral
infection.
308
In patients with acute symptoms of gastroparesis, what is the initial study of choice and why?
In patients with acute symptoms, upper endoscopy is the initial study to rule out pyloric
channel obstruction caused by PUD.
309
In patients with acute symptoms of gastroparesis, with negative findings on upper endoscopy what should be done next?
Patients with negative findings on upper endoscopy should undergo gastric
scintigraphy, wireless motility capsule, or gastric emptying carbon breath testing.
310
For patients with diabetes being worked up for gastroparesis, what should the blood glucose be less than for testing and why?
Patients with diabetes mellitus should have a blood glucose level <275 mg/dL
during testing because marked hyperglycemia can acutely impair gastric
emptying.
311
For patients with gastroparesis, what diet is recommended?
Specific dietary recommendations include small low-fat meals consumed four to five
times per day.
312
what is the difference in tx for acute gastroparesis vs chronic gastroparesis?
Use IV erythromycin for acute gastroparesis and metoclopramide for chronic
gastroparesis.
313
for patients with gastroparesis taking metoclopramide, what are the side effects to be aware of?
Dystonia and parkinsonian-like tardive dyskinesia are serious complications of
metoclopramide; the drug must be stopped at the first sign of these disorders.
314
Which vaccine is indicated for travelers to endemic areas, persons using injection
drugs, men who have sex with men, patients with chronic liver disease, patients with
HIV infection, homeless persons, and persons working in settings of exposure?
Hepatitis A vaccine is indicated for travelers to endemic areas, persons using injection
drugs, men who have sex with men, patients with chronic liver disease, patients with
HIV infection, homeless persons, and persons working in settings of exposure.
315
In nonimmunized persons recently exposed to HAV, when should they receive the HAV vaccine?
Nonimmunized persons recently exposed to HAV should receive the HAV vaccine within
2 weeks of exposure.
316
How is hep a virus transmitted.?
HAV is transmitted through the fecal-oral route.
317
Which clinical syndrome is associated with abrupt onset of fatigue, anorexia, malaise, nausea, vomiting, and jaundice.?
HAV is associated with abrupt onset of
fatigue, anorexia, malaise, nausea, vomiting, and jaundice.
318
For patients with unexplained acute hepatitis or acute liver failure what should they be tested for ?
Patients with unexplained acute hepatitis or acute liver failure should be tested for IgM
anti-HAV.
319
In previously unvaccinated persons, with needle-stick injury or sexual or household
contacts of patients with Hep B vaccine, what post expsoure prophylaxis in indicated?
In previously unvaccinated persons, hepatitis B vaccine plus HBIG is indicated for
postexposure prophylaxis after needle-stick injury and for sexual and household
contacts of patients with HBV.
320
what are the ways Hep B Virus is transmitted?
HBV is transmitted by exposure to the blood or body fluids of an infected person,
including through injection drug use, sexual contact with an infected person, or
transmission by an infected mother to her infant during delivery.
321
What is the tx for hep b virus?
Treatment usually consists of entecavir or tenofovir.
322
In patients coinfected with HIV and Hep B virus, what med combo is typically used as part of ART?.
In patients coinfected with HIV and who have not yet been treated for either disease,
emtricitabine-tenofovir is typically used as part of ART.
323
In persons with HBV, what are the 4 circumstances in which surveillance for HCC is recommended even in the absence of cirrhosis?
Surveillance for HCC is recommended even in the absence of cirrhosis in persons with
HBV who are at high risk:
* those with cirrhosis
* Asian men aged >40 years and Asian women aged >50 years
* persons from sub-Saharan Africa and aged >20 years
* those with a family history of HCC
324
Who should receive screening for hep c virus?
All adults aged 18 to 79 years should be screened at least once for HCV. Other high-risk
groups include persons who use injection drugs, recipients of blood transfusions before
1992, and those with HIV or an STI.
325
why does HCV usually manifests as chronic liver disease?
HCV manifests as chronic liver disease because the acute infection is usually
asymptomatic.
326
what are 2 severe consequences of Chronic HCV infection?
Chronic HCV infection can cause cirrhosis and is a risk factor for HCC.
327
The presence of what 4 conditions should make you also test for Hep C virus?
Test for HCV infection in the presence of non-Hodgkin lymphoma,
membranoproliferative glomerulonephritis, mixed cryoglobulinemia, and porphyria
cutanea tarda.
328
What is the initial diagnostic study for hep c?
Measurement of anti-HCV antibody is the initial diagnostic study.
329
If measurement of anti-HCV antibody is positive, what is the next best test to determine HCV RNA infection?
If positive, test for HCV RNA to determine the presence of active infection.
330
For patients with spontaneous resolution of acute HCV or who have been treated
successfully for HCV, what will hep labs show?
Patients with spontaneous resolution of acute HCV or who have been treated successfully for HCV will have clearance of HCV RNA but usually remain positive for antibody to HCV.
331
When Hep C virus is diagnosed what else should be done to help determine tx regimen?
HCV genotyping should be performed at the time of diagnosis to help in choosing a
treatment regimen.
332
Can normal aminotransferase levels exclude a diagnosis of HCV?
Because up to 40% of patients with chronic HCV have normal aminotransferase
levels, normal levels cannot exclude a diagnosis of HCV.
333
Before initiating direct antiviral therapy for HCV, what else should be tested? and why?
Reactivation of hepatitis B can occur during antiviral therapy for HCV. Test for
hepatitis B before initiating direct antiviral therapy for HCV.
334
Which clinical syndrome is associated with this pic?
Leukocytoclastic Vasculitis, Leukocytoclastic vasculitis consistent with HCV-associated mixed cryoglobulinemia
manifesting as palpable purpura.
335
What is the difference between UC and CD on endoscopy
UC is assoc with Altered crypt architecture with shortened, branched crypts and crypt abscesses
while CD is assoc with Granulomas are characteristic but are often not found.
Transmural involvement.
336
what lab should be considered to help
differentiate between IBD and IBS?
Fecal calprotectin should be considered to help
differentiate between IBD and IBS.
337
Is it safe to perform a barium enema examination in patients with moderate to severe ulcerative colitis ?
Do not perform a barium enema examination in patients with moderate to severe ulcerative colitis because this procedure may precipitate toxic megacolon.
338
what dx should be considered in patients with Crohn disease and cystitis?
In patients with Crohn disease and cystitis, consider the possibility of enterovesical fistula.
339
Before starting azathioprine or 6-MP what levels should be checked?
The level of thiopurine methyltransferase should be checked before starting
azathioprine or 6-MP; enzyme deficiency leads to increased levels of azathioprine and
6-MP, so these should not be used or dosages should be adjusted.
340
When should surveillance colonoscopy for colon cancer should be performed for patients with ulcerative pancolitis or Crohn disease
involving most of the colon?
Beginning 8 years after diagnosis, surveillance colonoscopy for colon cancer should be
performed every 1 to 2 years for patients with ulcerative pancolitis or Crohn disease
involving most of the colon.
341
In patients with UC or CD If dysplasia is found, what has to happen?
If dysplasia is found, proctocolectomy is required.
342
Before initiating an anti-TNF agent for UC or CD, all patients should be evaluated for what?
Before initiating an anti-TNF agent, all patients should be evaluated for TB and
hepatitis B and C virus infections.
343
Which clinical syndrome is associated with this pic?
Pyoderma Gangrenosum:
344
Which clinical syndrome is associated with A nonhealing ulcer, often occurring on the lower extremities, has a purulent base and ragged, edematous borders?
Pyoderma Gangrenosum
345
Which clinical syndrome is associated with recurrent abdominal pain at least 1 day per week for 3 months, as
well as at least two of the following:
* defecation-related pain
* change in stool frequency
* change in stool consistency
Irritable Bowel Syndrome
346
In patients with IBS-D, what 3 tests should be also ordered to further clarify the dx? t
In patients with IBS-D, test for celiac disease and giardiasis, and obtain fecal
calprotectin to differentiate from IBD.
347
what risk is associated with use of Alosetron.?
Alosetron should not be used as first-line therapy for IBS-D because of the risk of
ischemic colitis.
348
How does HELLP syndrome differs from AFLP ?
HELLP syndrome differs from AFLP in that HELLP syndrome is more closely
associated with microangiopathic hemolytic anemia and AFLP is more associated
with encephalopathy and coagulation abnormalities like low INR
349
How is HEELP syndrome differentiated from Preeclampsia?
Preeclampsia includes Hypertension, edema,
and proteinuria and HEELP has evidence of hemoylsis
350
How is Intrahepatic
cholestasis of
pregnancy tx?
Ursodeoxycholic
acid
351
How is Hyperemesis gravidarum different from Intrahepatic cholestasis of pregnancy?
HG occurs in 1st trimester, ICP occurs later in 2nd and 3rd
352
Which two clinical syndromes is associated with Acute, painless LGI bleeding in older adult patients?
Acute, painless LGI bleeding in older adult patients is usually caused by colonic
diverticula or angiodysplasia.
353
Which clinical syndrome is associated with Chronic blood loss or acute painless hematochezia in an older adult patient?
Colonic tumor, polyp, or angiodysplasia
354
Which clinical syndrome is associated with Recent colonic polypectomy and LGIB?
Postpolypectomy bleeding
355
Which clinical syndrome is associated with LGIB and Evidence of vascular disease in an older adult patient; typically with LLQ
abdominal pain?
Colonic ischemia
356
Which clinical syndrome is associated with Aortic stenosis and LGIB?
Angiodysplasia (Heyde syndrome)
357
Which clinical syndrome is associated with LGIB and Aortic aneurysm repair?
Aortoenteric fistula (UGI bleeding most
common)
358
Which clinical syndrome is associated with Painless hematochezia in a young patient and normal upper endoscopy and
colonoscopy?
Meckel diverticulum
359
when should colonoscopy be performed for LGIB hemodynamically stable patients
without rapid bleeding?
Select colonoscopy within 24 hours of admission for hemodynamically stable patients
without rapid bleeding.
360
how should hemodynamically unstable patients following resuscitation or ongoing bleeding be managed?
For hemodynamically unstable patients following resuscitation or ongoing bleeding:
* CTA
* catheter-based embolization if CTA positive
* upper endoscopy if CTA negative
361
Which clinical syndrome is associated with Poorly localized severe abdominal pain, often out of proportion to
physical findings; peritoneal signs signify infarction
Acute
mesenteric
ischemia
362
how is Acute
mesenteric
ischemia diagnosed?
CTA or selective mesenteric
angiography
363
Which clinical syndrome is associated with Postprandial abdominal pain, fear of eating, and weight loss; often, signs
and symptoms of atherosclerosis in other vascular beds?
Chronic
mesenteric
ischemia
364
Which clinical syndrome is associated with LLQ abdominal pain and self-limited bloody diarrhea?
Colonic
ischemia
365
how is Colonic
ischemia diagnosed?
Abdominal CT in all patients;
colonoscopy with biopsy, if possible
366
what does CT of Colonic Ischemia show?
CT scan showing segmental wall thickening and pericolonic fat stranding that is
consistent with colonic ischemia.
367
Which clinical syndrome is associated with this pic?
Colonic Ischemia
368
what is the tx for Chronic mesenteric ischemia?
Surgical bypass or angioplasty with stenting
369
what is the Treatment for acute Mesenteric Ischemia?
Broad-spectrum antibiotics
Surgical embolectomy or intra-arterial thrombolysis
Resection of necrotic bowel
370
what is the tx for Colonic ischemia?
Supportive care with IV fluids and bowel rest
371
which clinical syndrome is is characterized by chronic diarrhea, sometimes accompanied by
mild abdominal pain and weight loss, most commonly in women aged 45 to 60 years,
and is associated with other autoimmune conditions, particularly celiac disease. ?
Microscopic Colitis
372
How is Microscopic Colitis
Diagnosed?
Colonoscopy with biopsies is required for diagnosis. The colonic mucosa appears
normal on endoscopy.
373
Are patients with microscopic colitis are not at increased risk for colon cancer?
Unlike patients with IBD, patients with microscopic colitis are not at increased risk
for colon cancer.
374
What is the tx for microscopic colitis?
Discontinue potentially causative medications (NSAIDs, SSRIs, PPIs). Select symptom
management with antidiarrheal agents such as loperamide or bismuth subsalicylate.
Otherwise, budesonide has the best documented efficacy.
375
What is the most common cause of abnormal liver test results?
NAFLD is the most common cause of abnormal liver test results.
376
what conditions or risks factors are associated with Nonalcoholic Fatty Liver Disease ?
Most patients have insulin resistance, obesity, hypertriglyceridemia, and type 2 diabetes mellitus.
377
what are the main difference between HELLP and preeclampsia?
Preeclampsia has only Hypertension, edema,
and proteinuria while HELLP has abdominal pain, nausea, Hemolysis, elevated ALT, thrombocytopenia
378
what are the main difference between HELLP and AFLP?
Veery similar but AFLP has more hypoglycemia,
prolonged INR. You see more coagulation issues. HELLP syndrome differs from AFLP in that HELLP syndrome is more closely associated with microangiopathic hemolytic anemia and AFLP is more associated with encephalopathy and coagulation abnormalities.
379
What 3 factors can contribute to a presumptive diagnosis of NAFLD ?
A presumptive diagnosis of NAFLD can be made in a patient with:
* mildly elevated aminotransferase levels
* risk factors for NAFLD (diabetes, obesity, and hyperlipidemia)
* hyperechoic pattern on ultrasonography or low-density parenchyma on CT
380
What should be obtained in NAFLD pts to assess for significant hepatic fibrosis?
Transient elastography is obtained to assess for significant hepatic fibrosis.
381
When is liver biopsy is indicated to assess hepatic fibrosis in NAFLD pts?
Liver biopsy
is indicated when the diagnosis is in doubt or the presence of hepatic fibrosis cannot
otherwise be determined.
382
What is the treatment for NAFLD ?
Treatment for NAFLD consists of controlling diabetes, obesity, and hyperlipidemia.
383
what drugs are approved for nafld?
* No drugs are approved for the primary treatment of NAFLD.
* Patients with fatty liver disease and elevated aminotransferase levels can be
treated with statin therapy.
384
Which clinical syndrome is associated with nonspecific upper abdominal discomfort or nausea not attributable to PUD or GERD?
Nonulcer dyspepsia
385
Which drugs may cause dyspepsia?
Various drugs may cause dyspepsia, including NSAIDs, antibiotics, bisphosphonates,
and potassium supplements.
386
What are the two most common causes of Peptic Ulcer Disease?
Most PUD is caused by Helicobacter pylori infection or use of NSAIDs.
387
what are the 4 Complications of PUD?
Complications of PUD:
* Penetration is characterized by a gradual increase in the severity and frequency
of abdominal pain, with acute pancreatitis as a common presentation.
* Perforation is characterized by severe, sudden abdominal pain that is often
associated with shock and peritoneal signs.
* Outlet obstruction is characterized by nausea, vomiting, and/or early satiety and
a succussion splash.
* Bleeding is characterized by hematemesis, melena, or hematochezia (see Upper
GI Bleeding).
388
what are the 4 options for diagnosing h pylori?
Diagnostic tests for H. pylori should
be obtained. Options include:
* gastric biopsies during upper endoscopy
*
13C-urea breath test
* stool antigen test
* serologic testing (ELISA for IgG antibodies)
389
If a pt has a negative testing for H. pylori in the acute setting what should happen next?
Negative testing for H. pylori completed in the acute setting should be repeated
after discharge.
390
which drugs may give a False-negative rapid urease tests, urea breath tests, and stool antigen results for H. pylori?
antibiotics, bismuth-containing
compounds, or PPIs; these drugs should be stopped before testing (28 days for
antibiotics, 2 weeks for PPIs) or histologic assessment for H. pylori is performed.
391
what is the difference in timing to stop
antibiotics vs PPIs before h pylori testing?
antibiotics, bismuth-containing
compounds, or PPIs; these drugs should be stopped before testing (28 days for
antibiotics, 2 weeks for PPIs) or histologic assessment for H. pylori is performed.
392
what is the main downside to using Serum antibody testing for H. pylori ?
Serum antibody testing for H. pylori will not differentiate between past and
current infection; a negative test excludes infection, but a positive test cannot
confirm current infection.
393
Do duodenal ulcers require biopsy?
Duodenal ulcers carry little risk for malignancy and do not require biopsy unless
they are refractory to therapy.
394
what is the tx for peptic ulcer dz?
For uncomplicated PUD, begin once-daily PPI and stop any aspirin or NSAIDs. Treat H.
pylori if present.
395
In a pt with Aspirin or NSAID-Induced Bleeding Peptic Ulcer Disease, who is taking Aspirin for secondary prevention of CVD, how should the asa be managed?
Restart aspirin 1-7 days after initiation of PPI, and continue PPI indefinitely
396
in a pt with Aspirin or NSAID-Induced Bleeding Peptic Ulcer Disease who NSAID cannot be stopped permanently, how should the NSAID be given?
switch to a COX-2 inhibitor plus PPI
397
what is the tx for h pylori?
If resistance to clarithromycin is unlikely, use clarithromycin-based triple therapy.
398
When should you use bismuth quadruple therapy vs clarithromycin-based triple therapy?
* If resistance to clarithromycin is probable, use bismuth quadruple therapy.
399
In a pt with persistent h pylori infection after already having first line therapy, what is the next tx?
When first-line therapy fails, a salvage regimen (administered for at least 14 days)
should avoid previously used antibiotics.
400
When should follow-up noninvasive testing to document H. pylori eradication should be performed?
Follow-up noninvasive testing to document H. pylori eradication should be performed 4
weeks after completion of therapy by using a 13C-urea breath test, fecal antigen test, or
gastric biopsy.
401
what 3 options do you have to document H. pylori eradication ?
document H. pylori eradication by using a 13C-urea breath test, fecal antigen test, or
gastric biopsy.
402
When are Follow-up upper endoscopy for gastric ulcers indicated ?
Follow-up upper endoscopy for gastric ulcers is indicated if biopsies were not
performed during initial upper endoscopy.
403
Does duodenal PUD without complications does require follow-up?
Duodenal PUD without complications does not require follow-up upper
endoscopy.
404
can you use Serologic testing to confirm H. pylori eradication?
Serologic testing should not be used to confirm H. pylori eradication, because
results may remain positive in the absence of active infection.
405
Which clinical syndrome is associated with chronic progressive autoimmune cholestatic liver disease that occurs predominantly in women aged 40 to 60 years, Characterized by pruritus, fatigue, weight loss, hyperpigmentation, and/or
complications of portal hypertension?
Primary biliary cholangitis
406
When is a liver biopsy for PBC indicated?
In patients with negative antibody results and strong suspicion for PBC, liver biopsy is
necessary.
407
In a pt with PBC, in what 2 circumstances do you not have to get a liver biopsy to confirm a dx?
Diagnosis of PBC does not require a biopsy if:
* alkaline phosphatase level ≥1.5× ULN
* positive antimitochondrial antibody titer, or positive sp100 or gp210 if
antimitochondrial antibody is negative
408
Because PBC is associated with autoimmune disease; what lab should be checked yearly?
PBC is associated with autoimmune thyroid disease; TSH should be checked yearly.
409
Which patients with PBC should be screened for
hepatocellular carcinoma?
Men with PBC and patients with PBC and cirrhosis should be screened for
hepatocellular carcinoma.
410
What is the primary therapeutic agent for PBC?
Ursodeoxycholic acid is the primary therapeutic agent.
411
Which clinical syndrome is associated with characterized by progressive bile duct destruction and biliary cirrhosis?
Primary Sclerosing Cholangitis
412
How do you dx Primary Sclerosing Cholangitis?
MRCP establishes the diagnosis (look for the “string of beads” pattern).
413
What is seen on MRCP in Primary Sclerosing Cholangitis??
MRCP shows “string of beads” pattern). The diagnosis of PSC is established by demonstration of characteristic multifocal
stricturing and dilation of intrahepatic and/or extrahepatic bile ducts on
cholangiography (“string of beads”).
414
Which clinical syndrome is associated with this pic?
Primary Sclerosing Cholangitis
415
what are the three biggest risks that Patients with PSC are at risk for developing?
Patients with PSC are at risk for developing cholangiocarcinoma as well as gallbladder
carcinoma and colon cancer (when associated with IBD).
416
For patients with PSC, what 2 major screenings is recommended ?
1. Annual MRCP and carbohydrate 19-9 level measurement are recommended for
cholangiocarcinoma surveillance.
2. Screen for colon cancer with
colonoscopy every 1-2 years beginning at diagnosis of PSC,
417
what is the only effective treatment for PSC?
Liver transplantation is the only effective treatment.
418
Can you use capsule endoscopy in the setting of obstruction or strictures?
Do not use capsule endoscopy in the setting of obstruction or strictures (severe
Crohn disease).
419
In evaluation of suspected small bowel bleeding, what should be done if no source is found?
The first step is to repeat upper endoscopy and/or colonoscopy, particularly if initial
studies were of low quality, which is diagnostic in approximately 25% of patients. If
repeat studies are negative, perform small bowel evaluation.
420
For patients with small bowel bleeding, what are the differences in testing for stable vs unstable pts?
For unstable patients:
* CTA
For stable patients:
* capsule endoscopy
421
what are the 3 major causes of Upper GI Bleeding
?
Major causes: PUD, esophagogastric varices, and Mallory-Weiss tear.
422
In the setting of UGIB, should PPI be continued if no ulcer found on upper endoscopy?
stop PPI if no ulcer found on upper endoscopy)
423
In the setting of UGIB, and significantly elevated INR, what blood product should be used?
vitamin K or 4f-PCC for significantly elevated INR
424
In the setting of UGIB, when should aspirin be discontinued?
aspirin discontinuation (permanent) if being used for primary prevention,
continue if possible when used for secondary prevention. dual antiplatelet therapy for recent ACS or stent is discussed with cardiologist;
continue aspirin alone if P2Y12 inhibitor must be stopped
425
In the setting of UGIB, when should upper endoscopy be performed?
upper endoscopy within 24 hours; within 12 hours for suspected variceal bleed or
rapid bleeding
426
In the setting of UGIB, how are low risk ulcers treated compared to high risk ulcers?
low-risk ulcers are clean based or have a nonprotuberant pigmented spot; treat
low-risk ulcers with oral PPI, begin food, early hospital discharge (12-24 hours)
* high-risk ulcers have active arterial spurting or a nonbleeding visible vessel; treat
high-risk ulcers endoscopically (hemoclips, thermal therapy, or injection therapy)
and continuous IV PPI infusion for 72 hours
427
In the setting of UGIB, Can nasogastric tube be used for placement for diagnosis, prognosis, visualization, or therapeutic effect?
Do not select nasogastric tube placement for diagnosis, prognosis, visualization,
or therapeutic effect.
428
What dx should be considered in patients who previously had aortic graft surgery
and present with UGI bleeding?
Consider aortoenteric fistula in patients who previously had aortic graft surgery
and present with UGI bleeding.
429
In the setting of UGIB, what are the important post endoscopic care items to consider in terms of tx?
Postendoscopic care:
* test for H. pylori and treat if positive; retest if initial test was negative
* provide long-term, daily PPI therapy for patients who must use aspirin and other
antiplatelet drugs, NSAIDs, anticoagulants, or glucocorticoids
* provide nonselective β-blockers (propranolol, nadolol, or carvedilol) and
endoscopic band ligation for secondary prophylaxis of variceal hemorrhage
* restart aspirin as soon as possible if discontinued in patients with recent ACS or
stent
* restart P2Y12 inhibitor within 5 days if discontinued for UGI bleeding
