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GI Flashcards

1
Q

Treatment for chronic hep B

A

Tenofovir, Entecavir, or lamivudine (T and E are 1st line)
OR
Peg-interferon (cannot use in decompensated cirrhosis)

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2
Q

Treatment for Hep C

A

Sofosbuvir/Velpatasvir (Epclusa)
OR
Glecaprevir/Pibrentasvir (Maviret)

Check viral load 12 weeks post treatment completion

If negative, they are CURED.
SVR12 = sustained virological response 12 weeks

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3
Q

Treatment for MASH

A

Semaglutide (if they also have T2DM + obesity)

If no DM2, Vitamin E 800 IU daily

Bariatric surgery if obese

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4
Q

Components of Child-Pugh Score

A

A - albumin
B - bilirubin
C - coagulopathy
D - distension/ascites
E - encephalopathy

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5
Q

When do you give albumin in SPB?

A

If they have confirmed SBP, and for HRS prophylaxis:
Cr > 88, or
BUN > 10.7, or
Bili > 68

Give Albumin 1.5 g/kg on day 1
Then 1 g/kg on day 3

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6
Q

When do you do SBP prophylaxis?

A

1) if they’ve ever had SBP before - you prophylax forever

2) If the patient has cirrhosis and they come in with a GI bleed - SBP prophylaxis for 7 days. Doesn’t matter if they have ascites or not!!!

3) If they have ascites with ascitic fluid protein that is < 15 g/L AND one of:
- Impaired kidney fcn: Cr =/> 106, BUN =/> 8.9, Na =/< 130
- impaired liver fcn: CP =/> 9 AND bili =/> 51

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7
Q

Clinical manifestations of hereditary hemochromatosis

A

CNS: fatigue
HEENT: hypopituitarism (impotence, amenorrhea)
CVS: arrythmias
Resp
GI: Cirrhosis, elevated liver enzymes, DM, HCC
GU
MSK: 2nd and 3rd MCP hooked osteophytes (arthropathies), osteoporosis
Derm: hyperpigmentation (bronze/melanoderma), dryness, white nails, flat nails, koilonychia

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8
Q

DDx iron overload

A

Hereditary hemochromatosis
MASLD
EtOH liver disease
Hepatitis C
Chronic transfusions
Dyserythropoesis (sickle cell, thalassemia)

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9
Q

Treatment for HH

A

1st line phlebotomy targets: Ferritin 50–100
2nd line chelation With desferoxamine
Dietary recommendations: Avoid vitamin C supplements, avoid uncooked seafood, avoid red meat/dietary iron only if they are not undergoing phlebotomy

Procedural: transplant

Screen for HCC

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10
Q

Abnormal blood work in Crohn’s disease

A

↑ CRP, anemia, ↓ Albumin, ↓ Fe, ↓ B12, ↑ fecal calprotectin

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11
Q

Treatment for Crohn’s

A

Budesonide BUMP VISA
(Sulfasalazine only for MILD colonic crohn’s DZ)
prednisone
MTX
infliximab, adalumumab
vedolizumab
uestekinumab

MAINTENANCE
thiopurine/azathioprine < – this is the difference between induction and maintenance
same as above

if they have perianal disease (fistuals, abscesses) then you have to use infliximab /adalumumab

SURGERY if:
obstruction
refractory/fulminant dz
highgrade dysplasia/cancer
severe perianal disease/fistula,abscess
perforation

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12
Q

Treatment for eosinophilic esophagitis

A

Non-pharmacologic:
eliminate 6 foods: eggs, soy, cow’s milk, wheat, tree nuts, seafood.
“Tighter esophagus won’t swallow seafood, choking soy”

Pharmacologic:
1st line: PPI, topical steroids (swallowed fluticasone/budesonide)
2nd line: Prednisone

Procedural:
dilation endoscopically

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13
Q

Treatment IgG4/AI pancreatiits

A

NOn-pharm:

Pharm:
prednisone 40 mg PO daily x 4-6 weeeks, then taper
If relapse: AZA, ritixumab, or retrial steroids

Look for radiological improvement

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14
Q

Etiologies of chronic pancreatitis

A

TIGARO
Toxins/Metabolic: chronic EtOH, hyperTG, smoking, hyperCa, medications, toxins, CF
Idiopathic
Genetic: CF, CTRC
Autoimmune
Recurrent acute pancreatitis
Obstructive: stricture, stone, tumor, pancreatic divisum (2 pancreatic ducts)

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15
Q

Chronic pancreatitis treatment

A

Non-pharm
no smoking,
good diet
no EtOH

Pharm:
pancreatic enzymes
pain management: opioids, antioxidants

Procedural:
celiac plexus block
total pancreatectomy
islet cell autotransplant
ERCP

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16
Q

Side effects/risks of PPIs

A

CNS: dementia
HEENT:
Cardiac
Resp: pneumonia
GI: C. diff, gastric cancer
GU: AIN/CKD
Blood: hypoMg, hypo B12
MSK: low BMD

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17
Q

Elevated osmolar gap WITH anion gap

A

methanol
ethylene glycol

paraldehyde
ketoacidosis (etoh and diabetic)
lactic acidosis
severe CKD

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18
Q

Elevated osmolar gap SANS anion gap

A

isopropyl alcohol
ethanol
mannitol
sorbitol
EARLY or LATE toxic alcohol

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19
Q

Hyponatremia correction formula

A

volumeof infusate to give = [TBW x (desired Na - serum Na)] / [Na infusate]

Infusate = solution you choose to give
* Hypertonic saline 3%: 513mmol/L Na
* Normal Saline 0.9%:154mmol/L Na
* Ringers Lactate: 130mmol/L Na

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20
Q

Hyperkalemia DDx

A

* Increased intake **
– PO/IV K supplement
– Transfusions
* Decreased excretion
– Decreased tubular flow: CKD, Volume depletion
– Drugs- ACEi/ARB, NSAIDs, MRAs
– Hypo**aldosteronism: adrenal insufficiency, RTA type 4
* Shifting
– Cell lysis- TLS, Rhabdo, burns
– Metabolic- Acidosis, low insulin
– Hyperosmolarity: glucose, mannitol
– Familial hyperkalemic periodic paralysis
* Factitious
– Fist clenching/ tourniquet
– Hypercellular blood ( ie- heme malignancies)
* High WBCs, thrombocytosis
* Do a VBG/ABG! – no tourniquet and no centrifuge
= no hemolysis in tube
– Hemolyzed sample

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21
Q

Bloody diarrhea differential diagnosis: Bacterial

A

E. coli 0157
Shigella
Campylobacter
Salmonella
C. difficile rarely

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22
Q

Viral differential diagnosis for diarrhea

A

Rotavirus
Norovirus
CMV
Hepatitis A

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23
Q

Protozoa differential diagnosis for diarrhea

A

Giardia
Entamoeba histolytica
Cryptosporidium

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24
Q

Management of traveler’s diarrhea

A

Consider ciprofloxacin for:
More than 4 unformed stools daily, fever, blood, mucus, volume depletion, symptoms for more than 1 week, immunocompromised, and those where hospitalization is being considered

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25
Q

Diarrhea differential diagnosis

A

**Endocrine: **Hyperthyroidism, diabetes

**Inflammatory: **Ulcerative colitis, Crohn’s disease,
Infections: Salmonella, Shigella, Yersinia, Campylobacter, E. coli, C. difficile, amoeba, bacterial overgrowth, rotavirus, norovirus, CMV, Giardia, cryptococcus
Functional: Irritable bowel syndrome
Neuroendocrine: Carcinoid, VIPoma, Calcitonin normal, gastrinoma, somatostatin Oma,
**Malabsorption: **Pancreatic insufficiency, celiac disease, lactose intolerance, short gut syndrome, enteric fistula
**Medications: **Antacids, antibiotics, magnesium, colchicine, sorbitol, laxatives
**Others: **Bile salt enteropathy, collagenous colitis, lymphocytic colitis, fatty acid induced,
Radiation-induced

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26
Q

LGIB DDx

A

Brisk UGIB- 10-15%
Infectious
* Salmonella, shigella, campylobacter, yersinia, E. coli, c. diff, Entamoeba
Neoplastic
Inflammatory
* IBD
Ischemic (ischemic colitis)
Structural
* Angiodysplasia, diverticulosis, radiation, hemorrhoids, anal fissure, intussusception, Meckel’s

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27
Q

Ischemic colitis management

A

Non pharm:
* bowel rest
* serial abdo exams

Pharm
* broad spectrum ABX
* IV fluids

Procedural
* Surgery for infarction/fulminant colitis/hemorrhage/failure of med Rx/Recurrent sepsis, stricture

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28
Q

Extraintestinal manifestations of IBD

A

CNS:
HEENT: Uveitis, scleritis, aphthous ulcers
CVS:
Pulmonary: Pulmonary involvement
GI: Fatty liver, primary sclerosing cholangitis
GU:
MSK: Osteopenia, spondylitis, sacroiliitis, clubbing
Skin: Pyoderma gangrenosum, erythema nodosum
Type: Amyloidosis, venous thromboembolism, vitamin D12 deficiency

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29
Q

Pathology/endoscopy for Crohn’s disease

A

Cobblestone mucosa
Skip lesions
Granulomata
Transmural with fistula
Linear fissures

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30
Q

Ulcerative colitis pathology/endoscopy

A

Crypt abscesses
Deep ulcerations
Friable mucosa
Pseudopolyps

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31
Q

Stool osmotic gap

A

Osmolality stool (usually 290) - [2 x (sodium stool + potassium stool)]

<50 = secretory/motility. Therefore get CT scan, colonoscopy, hormone levels

≥ 50 = osmotic: Therefore empiric lactose-free diet, laxative screen

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32
Q

Celiac disease workup

A

TTGA IgA +/-IgA level
Duodenal biopsy
If biopsy and serology disagree, down’s syndrome, get HLA-DQ2 and DQ 8 genotyping

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33
Q

GI bleed mgmt

A

ICU/GI
ABC MOIF

PUD: IV pantoloc 80 mg bolus, then 8 mg/hr
Varices: octreotide 50 ug bolus, then 50 ug/hr x 72 hours
CTX 1 g IV daily for varices

Endoscopy

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34
Q

H pylori diagnosis

A

Stool antigen
Biopsy
Urea breath test

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35
Q

Hepatocellular enzyme elevation in the thousands

A

Toxins/drugs: Acetaminophen
Viral: Hepatitis A, B, D, E
Vascular: Shock, Budd-Chiari (Hepatic vein outflow tract obstruction)
Acute stone within the past 24 hours
Autoimmune hepatitis
Wilson’s disease

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36
Q

Hepatocellular enzyme elevation 100s

A

Viral: Hepatitis B, C, CMV, EBV
Alcoholic hepatitis AST>ALT

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37
Q

Hepatocellular enzyme elevation < a few 100

A

Autoimmune (celiac)
Metabolic dysfunction-associated steatohepatitis (MASH)/NASH
Hemochromatosis
Wilsons disease
Alpha 1 antitrypsin deficiency

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38
Q

Cholestatic enzyme elevation differential diagnosis

A

Extrahepatic/biliary duct dilatation:
Painful: Stones
Painless: Primary sclerosing cholangitis, benign obstruction (IgG4/autoimmune pancreatitis, AIDS cholangiopathy), malignant obstruction

Intrahepatic/no duct dilatation:
Drugs: Antibiotics, TPN, estrogens, methotrexate
Primary biliary cholangitis
Infections
Cholestasis of pregnancy
Infiltrative disease

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39
Q

Hepatitis A diagnosis

A

anti-HAV IgM

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40
Q

Hepatitis A management

A

Nonpharmacologic:
Postexposure prophylaxis for household contacts, coworkers and clients of infected food handlers, contacts in childcare

Pharmacologic: Can immunize against hepatitis A
Treatment is mainly supportive and the infection is self-limited

Procedural: Transplant for fulminant hepatitis

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41
Q

Interpret: sAb +

A

Immunized

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42
Q

sAg +
Core IgM +
eAg +
HBV DNA +

A

Acute infection

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43
Q

sAb +
Core IgG +
eAb +

A

Immune due to prior infection of hepatitis B

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44
Q

sAg +
Core IgG +
HBV DNA +
eAg +/-
eAb +/-

A

Chronic hepatitis

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45
Q

Core IgM +

eAg +/-
eAb +/-
HBV DNA +/-

A

Window period of hep B

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46
Q

Management of acute hepatitis B

A
  • Treatment is mainly supportive
  • Consider antiviral therapy
  • Ensure household and sexual contacts are immune and provide hepatitis B vaccine if they are not immune
  • No need for hepatitis B immunoglobulin for household contacts
  • Give hepatitis B immunoglobulin within 48 hours for sexual contacts and those with percutaneous exposure to high risk for source if there immune status is unknown
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47
Q

Management of chronic hepatitis B

A

Baseline workup for hepatitis B surface antigen positive:
Physical exam
FIBROSCAN
ALT, CBC, creatinine, HBV DNA, hepatitis B serology
HIV, hepatitis C

follow-up:
-ALT, HBV DNA q.6 – 12 months and repeat FibroScan if persistent elevated ALT and HBV DNA
-Ultrasound and AFP q.6 months for hepatocellular carcinoma surveillance if:
* All cirrhotics
* Asian male older than 40, Asian female older than 50
* African older than 20
* Family history of HCC in first-degree relative
* All HIV co-infected starting at age 40

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48
Q

List who to treat for chronic hepatitis B

A
  • Cirrhosis
  • Extrahepatic manifestations
  • Hepatitis B envelope antigen positive or negative With ↑ ALT, and HBV DNA ≥ 2000
  • Pregnancy at the end of the 2nd trimester or start of 3rd trimester with high DNA levels

Do not treat immune tolerant phase or inactive chronic hepatitis B phase with a normal ALT. Recall acute infection is generally managed supportively.

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49
Q

Alcoholic hepatitis diagnosis

A

AST > 50, AST/ALT > 1.5-2, and both values < 400, Tbili > 51

Clinical

50
Q

Management of alcoholic hepatitis

A

If Madrey score ≥ 32 or MELD score > 20 or encephalopathic: Start prednisolone 40 mg p.o. daily

At day 4 or day 7: Check Lille score. If <0.45, continue prednisolone for 28 days and then taper.
If ≥ 0.45, stop prednisolone and consider early liver transplantation

Assess for contraindications to steroids: Uncontrolled infection, uncontrolled GI bleed, AKI

Alcohol cessation and high caloric high-protein diet
NAC can be considered in addition to steroids

51
Q

MASLD: what is it?

A

Formerly NAFLD
Metabolic dysfunction-associated steatotic liver disease
Fatty liver no hepatocellular injury

Diagnosis = steatosis + rule out other secondary causes like alcohol

52
Q

WHat is MASH

A

Formerly NASH
Metabolic dysfunction-associated steatohepatitis (MASH) is the more severe form of MASLD
Has hepatocellular injury

Diagnosis = can only be definitively diagnosed on biopsy

53
Q

What is Met-ALD

A

MASLD + EtOH intake

54
Q

Management of metabolic associated fatty liver

A

Weight loss: Diet and exercise
Manage cardiovascular risk factors: Statins are safe
Pharmacotherapy: Semaglutide for MASH + type 2 diabetes/obesity
Bariatric surgery if obese

55
Q

What is the child Pugh score used for?

A

Predicts perioperative mortality for open abdominal surgery

56
Q

What is the MELD score used for?

A

≥ 15, refer for liver transplant assessment

57
Q

Cirrhosis complications and counseling

A

Assess for complications:
* Varices
* Ascites/spontaneous bacterial peritonitis
* Hepatic encephalopathy
* Hepatorenal syndrome
* Hepatopulmonary syndrome
* Portal pulmonary hypertension
* Hepatocellular carcinoma
* Frailty, malnutrition
**
Counseling:**
* Abstinence from alcohol, adequate nutrition, weight loss for metabolic associated dysfunction steatotic liver disease
* Acetaminophen ≤ 2 g/day
* Avoid sedatives, NSAIDs, ACE inhibitor/ARB’s
* Hepatitis A virus, hepatitis B virus, COVID-19, Tdap, pneumococcal, flu vaccinations, +/- zoster/MMR/varicella vaccines
* Refer to multidisciplinary team for frailty, sarcopenia or malnutrition
* Refer to palliative care if decompensated cirrhosis at any point in their journey

58
Q

Management of varices: Primary prophylaxis

A

Give carvedilol/nadolol/propranolol. Titrate to heart rate 55–60 and maintain SBP greater than 90
**OR **
Endoscopic variceal ligation

59
Q

Management of varices: Secondary prophylaxis

A

Carvedilol/propranolol/nadolol AND endoscopic variceal ligation

60
Q

Interpretation of SAAG greater than 11

A

Transudative = portal hypertension

61
Q

Interpretation of SAAG < 11

A

Exudative = malignancy, pancreatitis, infection like tuberculosis, nephrotic syndrome

62
Q

Portal hypertension ascites management

A

Nonpharmacologic:
Stop alcohol, treat underlying disease
Salt restriction

Water restriction if Na < 125

Pharmacologic: Spironolactone 100 mg + Lasix 40 mg daily, titrate up, monitor for hypotension, AKI, electrolyte imbalance

Procedural:
* Serial therapeutic paracenteses if failing medical therapy, give albumin 6-8 g/L of fluid removed For taps > 4 L
* Transjugular intrahepatic portosystemic shunt if no contraindications like encephalopathy or hepatocellular carcinoma
* Liver transplant

63
Q

Interpretation for 24-hour urine sodium < 78 in patients not on diuretics

A

Compliant with Sodium restricted diet

64
Q

Interpretation of 24-hour urine sodium greater than 78 in patient’s not on diuretics

A

Noncompliant with Sodium restricted diet

65
Q

**Interpretation of 24-hour urine sodium < 78 for patient’s on diuretics

A

They are diuretic resistant at the current doses
Therefore increase dose until limited by AKI, electrolyte abnormality, hypotension, etc.

66
Q

Interpretation of 24-hour urine sodium greater than 78 and the patient is not losing weight and they are on diuretics

A

They are noncompliant with a sodium restricted diet, therefore reinforce sodium restriction

67
Q

Interpretation of 24-hour urine sodium greater than 78 and the patient is losing weight and they are on diuretics

A

They are adherent to sodium restriction and are diuretic sensitive, therefore stay the course

68
Q

Management for confirmed SBP

A

Ceftriaxone x 5 days. Floroquinolone if they are allergic to penicillin

HRS prophylaxis: Day 1 albumin 1.5 g/kg + day 3 albumin 1 g/kg

Lifelong prophylaxis for SBP with norfloxacin, Septra double strength, or ciprofloxacin

69
Q

Diagnosis of celiac disease

A

Anti-TTG IgA & quantitative immunoglobulins (r/o ↓ IgA)
+/- anti-deamidated gliadin peptide [DGP] IgG (if ↓IgA)
+/- anti-endomysial antibody [EMA]

Upper endoscopy with small-bowel biopsy – Marsh Classification

HLA DQ2/DQ8 Testing

70
Q

Celiac disease management

A

Lifelong gluten-free diet: BROW (barley, rye, oats, wheat)

Follow-up:
Diet history
↓ antibody titers + /-improvement of histology
Follow-up serologies 6 and 12 months postdiagnosis, then annually
Monitor iron, folate, vitamin D, vitamin B12
Bone mineral density per guidelines

71
Q

Complications of celiac disease

A

Nutritional deficiencies and anemia
Osteopenia/osteoporosis
Elevated liver enzymes
Dermatitis herpetiformis
Enteropathy associated T-cell lymphoma

72
Q

Management of dermatitis herpetiformis

A

Gluten-free diet
Dapsone after ruling out G6PD deficiency

73
Q

Indications for surgery and Crohn’s disease

A

Intestinal obstruction
Refractory/fulminant disease
High-grade dysplasia/cancer
Severe perianal disease/fistula/abscess
Perforation

74
Q

Need to do if the patient has Crohn’s disease and pain and fever

A

Look for a collection/abscess

75
Q

Management of abscess in Crohn’s disease

A

I&D/surgery/interventional radiology and antibiotics (Cipro + Flagyl or ceftriaxone/Flagyl) prior to immunosuppression

76
Q

Management of fistula in Crohn’s disease

A

Get endoscopic ultrasound or MRI pelvis +/- exam under anesthesia to characterize a perianal fistula
**
Start anti-TNF **to induce a symptomatic response and to maintain the remission
Other options: Vedolizumab/ustekinumab or surgery

77
Q

What to do with a cold stricture and Crohn’s disease

A

Conservative management: Bowel rest, NG tube
Endoscopic dilation or surgery

78
Q

What to do with a hot stricture in Crohn’s disease

A

Steroid bridge to maintenance therapy, usually Biologics

79
Q

Disease locations of ulcerative colitis

A

Proctitis (i.e. within 18 cm from the anal verge)
Left-sided colitis: Sigmoid to the splenic flexure
Extensive/pancolitis: Beyond the splenic flexure

80
Q

Diagnosis of ulcerative colitis

A

Need ileocolonoscopy + biopsy: Continuous inflammation from rectum proximally, granular, friable mucosa
Biopsy shows** crypt abscesses**

81
Q

Ulcerative colitis treatment options

A
82
Q

what to do before starting a biologic for IBD?

A

Hepatitis B virus, hepatitis C virus, TB skin test/chest x-ray/IGRA, VZV titers, strongyloidiasis testing

Before starting AZA/6MP, check TPMT

Check** fecal calprotectin**, since it is used as a marker of disease activity

83
Q

Management of inpatient IBD flares

A

Rule out C. difficile

Rule out abscess in a Crohn’s patient with fever + abdominal/perianal pain

Withhold immunosuppression until the 2 above are addressed

Check CMV because CMV colitis can coexist with IBD and requires biopsy to diagnose

Do not stop DVT prophylaxis even if the patient is having bloody diarrhea

If they have bile salt diarrhea: Cholestyramineafter treating active IBD

Start IV steroids once infection is ruled out. If minimal response after 72 hours of IV steroids, start infliximab.

Consider general surgery consultation for refractory colitis, toxic megacolon, perianal/intra-abdominal abscess, complex fistulizing Crohn’s

84
Q

What is the score that is used to identify low risk patients that can be discharged after an upper GI bleed with outpatient follow-up

A

Glascow Blatchford score

85
Q

What is indicated for any GI bleed in a patient with cirrhosis?

A

Prophylaxis with ceftriaxone 1 g IV q.24 hours x 5-7 days

86
Q

Testing options to detect CURRENT infection of H. pylori

A

Stool antigen
Histology
Biopsy culture
Urea breath test

87
Q

Testing options to detect current or prior infection of H. pylori

A

Serum IgG

88
Q

Treatment for H. pylori

A

First line: PBMT or PAMC x 14 days
* PPI/Bismuth/Metronidazole/Tetracycline (PBMT)
* PPI/Amoxicillin/Metronidazole/Clarithromycin (PAMC)

– Treatment failure:
* PBMT (if prior triple-therapy) x 14 days OR
* PPI/Amoxicillin/Levofloxacin (PAL) x 14 days

  • Confirm eradication in all treated patients
    – Urea breath test, stool antigen test, or repeat gastric biopsy

Wait ≥ 4 weeks after completing antibiotic therapy and ≥ 1-2 weeks after PPI therapy before testing for H. pylori to improve test accuracy!

89
Q

Management of Barrett’s esophagus if there is no intestinal dysplasia, but There is metaplasia

A

Get an EGD in 3 years if there is a > 3 cm segment of salmon mucosa, otherwise get an EGD in 5 years

90
Q

Management of Barrett’s esophagus if there is indefinite dysplasia

A

Start a PPI BID and repeat the EGD with biopsy in 6 months

91
Q

Management of Barrett’s esophagus if there is low grade dysplasia

A

Surveillance endoscopy every 6 months 2 times then annually

Or
Endoscopic eradication therapy followed by surveillance endoscopy 1 year then every other year thereafter

92
Q

Management of Barrett’s esophagus with high-grade dysplasia or intramucosal carcinoma

A

Endoscopic eradication therapy with complete eradication and then surveillance endoscopy 3, 6, 12 months afterwards then annually

93
Q

Management of Barrett’s esophagus for submucosal cancer

A

Surgical referral for esophagectomy

94
Q

Modified barium swallow versus barium swallow

A

Modified barium swallow: Takes pictures of the Mouth and throat

Barium swallow: Takes pictures of the throat and esophagus

95
Q

Complications of achalasia

A

Megaesophagus > 6 cm
Sigmoid esophagus
Esophageal squamous cell carcinoma

96
Q

Diagnosis of achalasia

A

Step 1: EGD to rule out pseudo achalasia + obstruction

Step 2: High-resolution manometry +/- barium swallow. Will see BirdBeak esophagus

97
Q

Management for achalasia

A

Depends if they’re poor or good surgical candidate

Poor surgical candidate: Endoscopic Botox injection, nifedipine 10-30 mg sublingual TID, ISDN 5 mg sublingual TID

Good surgical candidate: Pneumatic dilation, laparoscopic Heller myotomy, per oral endoscopic myotomy, esophagectomy (latter for megaesophagus, sigmoid esophagus, failure of the above treatments)

98
Q

Treatment for eosinophilic esophagitis

A

Eliminate 6 foods: Eggs, soy, cows milk, wheat, tree nuts, seafood

Pharmacologic: PPI, topical steroids like swallowed fluticasone/budesonide
2nd line: Prednisone

Endoscopic treatment for symptomatic strictures: Dilation

99
Q

Etiologies of acute pancreatitis

A

Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps/Malignancy
Autoimmune pancreatitis
Scorpion venom
Hyperlipidemia/hypercalcemia
ERCP
Drugs including OCPs/HRT, thiazides, 5-ASA, AZA, GLP1agonist

100
Q

Management of acute pancreatitis

A

ABC MOIF / ICU
IV fluids: ringer’s lactate
Analgesia
Nutrition: Start clear fluids or low-fat diet early within 24 hours, advance as able, if unable to take p.o. then get an NG tube
Only start antibiotics if there is evidence of cholangitis or sepsis

101
Q

Management of pancreatic necrosis

A

If patient is systemically well: Obtain CT-guided FNA and if the Gram stain is negative, it means it is a sterile necrosis. Do supportive care and consider repeat FNA every 5-7 days

If the patient is septic: Given empiric necrosis penetrating antibiotics such as carbapenems, get the Gram stain and if it is positive and they are unstable then get a prompt** surgical debridement**. If they are clinically stable then continue antibiotics and observe.

102
Q

Management of acute gallstone pancreatitis

A

Urgent ERCP if cholangitis or persistent biliary obstruction or severe ongoing pancreatitis

Ideally, cholecystectomy before discharge

103
Q

Management of hypertriglyceridemia induced pancreatitis

A

If they are sick, give IV insulin and strict n.p.o. +/- plasmaphoresis

Ideally, cholecystectomy before discharge

Long-term: Fibrates, restrict dietary fat, treat secondary causes of hypertriglyceridemia such as diabetes and alcohol

104
Q

Early < 4 weeks complications of acute pancreatitis

A

Interstitial edematous pancreatitis
Acute peripancreatic fluid collection
Pancreatic necrosis
Infected pancreatic necrosis

105
Q

Late complications of acute pancreatitis

A

Pseudocysts that require endoscopic or surgical drainage
pancreatic abscess
Walled off pancreatic necrosis

106
Q

Workup indicative of IgG4/autoimmune pancreatitis

A

CT/MRCP + EUS shows sausage pancreas
Biopsy shows lymphoplasmacytic infiltrates and fibrosis
There are biliary strictures

Serum Ig G4 is more than 2 times the upper limit of normal

107
Q

Treatment of IgG4/autoimmune pancreatitis

A

Prednisone 40 mg daily x 4-6 weeks, then taper
If relapse, retrial of a steroid or start azathioprine or rituximab

Look for radiologic improvement

108
Q

Etiologies of chronic pancreatitis

A

TIGAR-O”
– Toxic/metabolic: CHRONIC alcohol use, hyperTG, Smoking, hyper Ca, Medications, Toxins…Cystic Fibrosis
– Idiopathic
– Genetic – CF, and others PRSS1, CTRC…
– Autoimmune pancreaoos
– Recurrent Acute Pancreatitis (RAP)
– Obstructive: i.e. pancreatic divisum (2 distinct pancreaoc ducts, not one), stricture, stone, tumor

109
Q

Management of chronic pancreatitis

A

Nonpharmacologic: Alcohol and smoking cessation for all

Pharmacologic: Pancreatic enzyme
Antioxidants like selenium, ascorbic Axid, methionine, opioids for pain

Procedural:
Celiac plexus block for pain
Total pancreatectomy + islet cell autotransplant

110
Q

DDx lower GI bleed

A

Brisk upper GI bleed
Diverticular bleed
Hemorrhoids
Angiodysplasia
Polyp/post polypectomy
Cancer
Ulcers
Radiation proctitis
Meckel’s diverticulum
Ischemic colitis
Anal fissure
IBD

111
Q

Diagnosis of microscopic colitis

A

Normal colonoscopy, but biopsies confirm diagnosis

112
Q

Management of microscopic colitis

A

Imodium, stop NSAIDs or other offending medications like PPI/lansoprazole, SSRI, pembrolizumab

Start budesonide p.o. as first-line, 2nd line is 5 ASA p.o.

113
Q

Imaging findings suggestive of primary sclerosing cholangitis

A

Beads on a string on an MRCP

114
Q

Management of primary sclerosing cholangitis

A

ERCP for symptomatic strictures
MRCP +/- CA 19–9 every year to screen for gallbladder cancer and cholangiocarcinoma
**Colonoscopy with surveillance biopsies **at diagnosis and every 1-2 years
If cirrhotic, screen for hepatocellular carcinoma
Ursodeoxycholic acid has no evidence but frequently used
Liver transplant for liver failure

115
Q

Diagnosis for primary biliary cholangitis

A

Diagnosis requires 2 of 3:
Persistent ALP elevation > 6 months
Positive AMA > 1:40 or Specific ANAs
Liver biopsy only needed when diagnosis is unclear

116
Q

Management of primary biliary cholangitis

A

Bone density testing, lipid profile derangement, monitor for cirrhosis

Ursodeoxycholic acid 15 mg/kg has benefit

Liver transplant for liver failure

117
Q

Clinical picture of hepatopulmonary syndrome

A

Platypnea/orthodeoxia
PaO2 < 80
AA gradient > 15

TTE bubble study would show a shunt

118
Q

Management of hepatic encephalopathy

A

Treat underlying cause

Lactulose

+/- Rifaximin if patient had hepatic encephalopathy while already on lactulose

High-calorie, high-protein diet

Procedural: Recurrent intractable HE together with liver failure is an indication for liver transplant

119
Q

DDx portal hypertension

A

Cirrhosis
Congestive heart failure
Constrictive pericarditis
Hepatic vein thrombosis/Budd-Chiari syndrome
Portal vein thrombosis

120
Q

Max dose of spironolactone and furosemide for ascites

A

Spironolactone 400 mg/day, furosemide 160 mg/day

121
Q

Causes of acute pancreatitis

A

Idiopathic

Gallstones
Ethanol
Trauma

Steroid use
Mumps
Autoimmune
Scorpion bites
Hypercalcemia/hyperTG
ERCP
Drugs/meds

122
Q

Dyspepsia DDx

A

Dyspepsia = fullness + early satiety + post-prandial abdo pain
● Vascular: mesenteric ischemia
● Infectious: **H. pylori, **Chagas
● Toxic: NSAIDs, bisphosphonates, alcohol
● Autoimmune: scleroderma, GI Crohn’s, Celiac
● Metabolic: gastroparesis from diabetes
● Idiopathic: functional dyspepsia
● Neoplastic: gastric cancer
● Structural: GERD, biliary colic, pancreatic insufficiency

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