Flashcards in GI Deck (192)
A pt presenting with progressive dysphasia to both liquids and solids at same time and regurgitation several hours after meals suffers from ...
Achalasia (inability to relax LES)
What is the best initial test for Achalasia?
barium swallow (bird's peak)
What is the most accurate test for Achalasia?
manometry (increased LES pressure; decreased LES tone)
What is the best initial treatment for Achalasia?
(followed by Botox, myometry)
An older pt who drinks and smokes presents with progressive dysphasia that starts as just to solids and progresses to liquids and weight loss most likey suffers from ...
Esophageal cancer (Squamous cell)
(associated with long standing GERD)
What type of cancer occurs in proximal 2/3 of esophagus?
Squamous cell carcinoma
What type of cancer occurs in distal 1/3 of esophagus?
What is the best test for esophageal carcinoma?
Endoscopy w/ biopsy
(do CT scan for local spread; endoscopic U/S for staging)
What is the most accurate test for esophageal dysphagia in scleroderma patients?
What is the best treatment for pts with esophageal dysphagia and scleroderma?
PPI (can add metoclopramide)
A pt with intermittent chest pain along with dysphasia, usually precipitated by cold liquids most likely suffers from ...
diffuse esophageal spasm/ Nutcracker esophagus
What is the finding on barium swallow for Nutcracker esophagus/ diffuse esophageal spasm?
corkscrew appearance (at time of spasm)
What is the most accurate test for Nutcracker esophagus/ diffuse esophageal spasm?
manometry (high intensity, disorganized contractions)
What is the treatment for Nutcracker esophagus/ diffuse esophageal spasm?
1. calcium channel blockers (nifedipine)
A patient with history of regurgiting undigested food, especially at night, and can express food via pushing on their throat most likely suffers from ....
What is the best initial test for Zenker's diverticulum?
What is the treatment for Zenker's diverticulum?
surgery (avoid endoscopy, NG tubes)
.... is thin epithelial membranes made from squamous cells located at squamocolumnar junction proximal to LES that causes intermittent dysphagia
... are epithelial membranes made of squamous cells loacted in hypopharynx, causes intermittent dysphagia, associated with iron deficiency and squamous cell cancer
(tx w/ dilation and iron)
An HIV pt with CD4 count less than 200 presenting with odynophagia (pain with swallowing) most likely presents with ....
What is the treatment for Candida esophagitis?
A patient on bisphosphonates or acne meds presenting with odynophagia most likely suffers from ...
Esophagitis (due to pill)
(treat with swallow pill in upright position with lots of water)
A pt presents with painless upper GI bleed after repeated episodes of retching and vomiting most likely presents with ...
What is the diagnostic tool of choice for Mallory-Weiss syndrome?
What treament is used for Mallory Weiss syndrome?
2. can inject epi or cauterize if necessary
What test for H. pylori is not affected by PPI use?
H. pylori ELISA
When should a pt with epigastric pain undergo endoscopy?
1. older than 55 y/o
2. alarm symptoms (bleeding, weight loss, dysphagia)
3. if symptoms not resolved with PPI
What is the most accurate test for GERD?
24 hour pH monitoring
A pt presents with epigastric pain, sore throat, metallic taste, hoarseness and cough most likely suffers from...
What is the next best step in a patient presenting with GERD or signs of peptic ulcer disease (<45 y/o) without alarming symptoms?
treat with PPI
What things should people avoid if they have GERD?
What is the surgical treatment for GERD and when is it indicated?
1.refactory side effects of PPI (headaches, diarrhea)
2. no response to PPI
.... is a complication of long standing reflux in which epithelium of lower esophagus changes from squamous to columnar
How often should endoscopy be repeated in pts with Barrett's esophagus?
every 2-3 years
(every 3-6 months if low grade dysplasia)
What is the best treatment for Barrett's esophagus?
A patient with midepigastric pain that is relieved by eating and not associated with weight loss is most likely ...
A patient presenting with epigastric pain that is worsened by food and associated with weight loss is most likely ...
(always biopsy to exclude cancer)
What tests are used to assess whether H. pylori treatment was successful or if recurred after remission?
1. urea breath test
2. stool antigen
What are the two most common causes of peptic ulcer disease?
1. H. pylori
2. NSAIDs use
What is the treatment for H. pylori associated peptic ulcers?
(for 10-14 days)
What are the indications for stress ulcer prophylaxis?
1. mechanical ventilation
3. head trauma
4. severe coagulopathy with sepsis
A patient presents with peptic ulcer disease despite max dose of PPI and H2 blocker and associated diarrhea most likely suffers from ...
(diarrhea due to lipase inactivation by acids)
What are the diagnositic for Zollinger-Ellison syndrome?
1.elevated gastrin level with pt off PPI/H2 blocker for few days
2. secretin stimulation (positive if elevated gastrin)
What diagnostic tools are used to assess whether gastrinoma is metastasized?
1. Somatostatin-recpetor scintigraphy
2. endoscopic ultrasound (most sensitive)
A poorly controlled diabetic presents with early satiety, post-prandial nausea, abdominal fullness and bloating most likely suffers from ...
(b/c can't feel stretch so no gastrin release)
What is the treatment for gastroparesis?
What disease can occur in a pt with history of vagotomy and gastric resection for severe peptic ulcer disease?
What is the sequence of events involved in dumping syndrome?
1. rapid release of chyme in duodenum --> osmotic draw --> intravascular volume depletion
2. rapid release of chyme in duodenum --> peak of glucose --> rapid release of insulin --> hypoglycemia
A pt presents with sweating, shakiness, palpitations and lightheadedness shortly after a meal most likely suffers from ..
What is the treatment for Dumping syndrome?
eat multiple, small meals
A pt who has epigastric pain but all other causes have been excluded most likely suffers from ..
(treat via symptomatic relief)
What are the findings on endoscopic exam for Crohn's disease?
skip lesions with transmural inflammation throughout bowels
What are findings in barium studies for Crohn's disease?
What is the difference between Crohn's disease and Ulcerative colitis?
Crohn: skip lesions, trasmural, fistula formation, granulomas forming abdominal masses, through GI tract
UC: no skip lesions, mucosal, no fistulas,no granulomas, only in colon, bloody diarrhea
A pt presenting with fever, diarrhea, weight loss, and abdominal pain that has positive for Anti-Saccharomyces cerevisiae antibodies most likely suffers from ...
A pt presenting with fever, diarrhea, weight loss, and abdominal that has positive ANCA (anti-neutrophil cytoplasmic antibody) most likely suffers from ...
What are treatments for chronic treatment of Crohn's disease?
1. pentasa (mesalamine derivative)
4. Infliximab (if fistula or refractory to others; test for TB first)
What is use for acute exacerbations of Ulcerative colitis and Crohn's?
What treatments are used for chronic treatment of Ulcerative colitis?
1.asacol, rowasa, sulfasalazine (mesalamine derivatives in colon)
What are common side effects of sulfasalazine?
1. reversible infertility in men
3. sulfa effects (rash, hemolysis, allergic interstitial nephritis)
What is a side effect that can occur with the use of azathioprine and with the use of 6-MP?
What is the most important thing to do before starting treatment with infliximab?
test for latent TB with PPD
(can induce re-activation of TB)
What is the first thing to do in a patient with diarrhea?
assess for hypovolemia (hypotensive or orthostatic hypotension; tachycardia)
What tests should be done to exclude infectious diarrhea?
1. fecal leukocytes
2. stool culture
3. ova and parasite exam
4. C. difficile toxin (if clues in hx)
5. Giardia-ELISA antigen testing (if clues in hx)
What are the two most common causes of infectious diarrhea?
A pt develops diarrhea and vomiting shortly after eating Chinese food most likely suffers from ...
Bacillus cereus infection (pre-formed toxins)
A pt has history of diarrhea and develops Guillian Barre syndrome or reactive arthritis most likely had diarrhea due to ...
What are the most likely causes of diarrhea in an HIV pt with CD4 count less than 100?
A pt develops diarrhea (bloody) after eating a hamburger most likely is infected with ...
What is a common complication of infection with E. Coli 0157:H7?
HUS (hemolytic uremic syndrome)
-avoid abx b/c organism already dead at this point
-avoid platelet tranfusion b/c make it worse
A camper or mountain hiker develops diarrhea with abdominal fullness, bloating and gas most likely suffers from ....
(associated with fat and vitamin malabsorption)
A pt develops diarrhea after ingesting chicken, eggs, and dairy products most likely suffers from ...
A pt develops diarrhea, flushing, wheezing, and vomiting within minutes of eating fish most likely suffers from ...
Scombroid infection (release histamine into fish)
What are the most common causes of diarrhea in an iron overloaded patient (hemochromatosis)?
3. Vibrio vulnificus
What infectious diarrheal organism can mimic appendicitis?
A pt presents with hx of chronic liver disease and diarrhea after eating raw shellfish (muscles, oysters, clams) most likely suffers from ...
Vibrio (vulnificus and parahaemolyticus)
What is the difference between infection with vibrio vulnificus and vibrio parahaemolyticus>
vulnificus: iron loaded pt (hemochromatosis); skin bullae
parahaemolyticus: not above
What is the most common cause of diarrhea in children at day-care?
A pt develops nausea and vomiting (with mild diarrhea) shortly after eating dairy products, eggs, salads most likely suffers from ...
S. aureus (pre-formed toxins)
A pt develops diarrhea along with neuro symptoms (paresthesia, weakness, reversal of heat/cold) after eating large reef fish (grouper, red snapper, barracuda) most likely suffers from ...
What is the diagnostic test for Cryptosporidiosis?
modified acid fast test
What is the best empiric therapy for infectious diarrhea?
2. other fluroquinolone with metronidazole
(if pain, fever, blood, tender)
What is the best treatment for Scombroid?
What is the best treatment for Giardia?
metronidazole (can also use single dose tinidazole)
What is the best treatment for cryptosporidiosis?
1. raise CD4 count (anti-retrovirals)
What is the best treatment for diarrhea caused by Isopora?
What is the best treatment for Vibrio vulnificus?
What is the best treatment for traveller's diarrhea (E. Coli)?
(never prophylactic antibiotics)
A pt presents with profuse watery diarrhea and a history of recent antibiotic treatment most likely suffers from ...
What is the best diagnostic test for C. difficile?
stool toxin for C. difficile
What is the best treatment for C. difficile associated colitis?
Metronidazole (oral or IV)
(second line is oral vancomycin if persisted despite metronidazole)
What medication can be used to decreased the frequency of recurrent episodes of C. difficile colitis?
A pt presenting with gas, bloating and diarrhea associated with ingestion of dairy products most likely suffers from ...
Lactose Intolerance (usually starts around 12 y/o)
What diagnostic tests can be used to diagnosis lacotse intolerance?
1.increased stool osmolality
2. increased osmolar gap (difference btw stool osmolality is greater than expected with level of Na and K; >50)
What is the best initial test for lactose intolerance?
remove milk, cheese, ice cream and other dairy products from diet
(symptoms resolve within 24-36 hours)
A pt presenting with abdominal pain that is relieved by bowel movements, diarrhea and/or constipation most likely suffers from ...
irritable bowel syndrome
What is Rome criteria and what disease is it used for?
following symptoms for at least 3 months
1. pain relieved by bowel movement/ change in bowel habits
2.fewer symptoms at night
3. diarrhea alternating with constipation
used for irritable bowel syndrome
What are treatments used in irritable bowel syndrome? (5)
1. high fiber diet
2. anti-diarrheal (loperamide, diphenoxylate)
3. antispasmodics (hyoscyamine, dicyclomine, belladonna alkaloids)
4. TCAs (have anticholinergic effect)
5. tegaserod (for constipation predominant)
6. alosetron (for diarrhea predominant)
What antibiotics can be used for the peri-rectal/ peri-anal disease associated with Crohn's disease?
Ciprofloxacin with Metronidazole
What are the side effects associated with sulfa drugs (i.e. sulfasalazine)? (3)
1.drug induced hemolysis
3. renal (allergic interstitial nepritis)
What medication is used for fistula formation associated with Crohn's disease?
If patient has crohn's disease of colon or ulcerative colitis for more than 8 years, have an increased risk of .....
(scope after 10 years of IBD)
What is the liver disease associated with ulcerative colitis and crohn's disease?
Primary Sclerosis Cholangitis
What is a curative treatment for ulcerative colitis?
Colectomy (surgical removal of colon)
What is the complication of surgery for Crohn's disease?
recurrence at site of surgery
If have positive fecal leukocytes or fecal blood in the setting of diarrhea, what are likely infectious causes?
Invasive disease (Salmonella, Yersinia, Shigella: white cells)
(Campylobacter, E.Coli, Vibrio parahemolyticus: red cells)
What should you avoid in the treatment of a pt with E.Coli 0157:H7 associated HUS?
1. avoid antibiotics (killing bacteria release more toxin)
2. avoid platelet transfusion (makes it worse)
An elderly pt presents with colicky LLQ pain with painless bleeding most likely suffers from..
Diverticulosis (outpouching of colon)
What is the diagnostic test of choice for Diverticulosis?
What is the treatment for Diverticulosis?
increase fiber (bran, metamucil, bulking agents, psyllium husks)
A pt presents with intermittent flushing, wheezes, diarrhea, tachycardia and hypotension most likely suffers from ...
Carcinoid syndrome (serotonin release- lung or appendix)
What are the cardiac complications associated with Carcinoid syndrome?
1. tricuspid insufficiency
2. pulmonic stenosis
What is the treatment for diarrhea for carcinoid syndrome?
What is the diagnostic test of choice for carcinoid syndrome?
A patient presents with greasy, oily, floating and fatty stools that are particularly foul smelling and weight loss most likely suffer from ...
fat malabsorption syndromes (celiac disease, chronic pancreatitis, tropical sprue, whipple disease)
What is the best treatment for tropical sprue?
What is the best inital diagnostic test for Celiac disease?
What is the most accurate diagnostic test for Celiac disease?
Small bowel biopsy (flattening of villi)
What is the best treatment for Whipple's disease?
1. bactrim or doxycyline
A pt presents with fat malabsorption after visiting a tropical country most likely suffers from ...
What is d-xylose testing used for?
distinguish btw normal bowel wall versus abnormal bowel wall for fat malabsorption syndromes
A pt presents with fat malabsorption with dementia, arthalgias, and ophthalmoplegia most likely suffers from ...
What is the most sensitive test for Whipple's disease?
PCR of bowel biopsy
What findings on bowel-wall biopsy in patients with Whipple disease?
foamy macrophages that are PAS positive
What is the most accurate test for chronic pancreatitis?
secretin testing (no bicarb release with secretin injection via NG tube)
A pt presenting with fever, tenderness, leukocytosis, and intense LLQ pain most likely suffers from...
Diverticulitis (inflammation of outpouching)
What is the best diagnostic test for diverticulitis?
CT scan (avoid barium swallow and endoscopy b/c increases perforation)
What is the Sudan Black test?
detects fat in stool (used to detect fat malabsorption)
What is the best treatment for diverticulitis?
Ciprofloxacin with metronidazole
What vitamin deficiencies are associated with fat malabsorption?
1.vitamin D (decrease calcium)
2. vitamin A
3. vitamin K (increased PT; easy brusing)
4. vitamin E
What are unique findings in Celiac disease compared to other fat malabsorption syndromes?
1. iron deficiency
2. folate deficiency
3. dermatitis herpetiformis
..... is vesicular skin rash on extensor surfaces of the body seen in Celiac disease
What are common causes of constipation? (6)
1. calcium channel blockers
2. iron supplement (not absorbed so stuck in stool)
5. anticholinergics (TCAs)
If polyps are detected on colonoscopy, when should repeat colonscopy?
In general population, when should colon cancer screening start and how often if normal?
at age 50 y/o, every 10 years
Endocarditis due to what organism is associated with increased likelihood of colon cancer?
Strep bovis (colonoscopy screening immediately)
A pt with 3 family members in at least 2 generations that were found to have colon cancer (1 prior to 50 y/o) most likely suffers from..
Hereditary Nonpolyposis Syndrome (lynch syndrome)
What is the colon cancer screening recommendations for pt with Hereditary Nonpolyposis Syndrome?
colonoscopy q 1-2 years starting at 25 y/o
A pt with multiple polyps associated with defect in APC gene most likely suffers from ...
Familial adenomatous polyposis
What is the screening recommendations for familial adenomatous polyposis?
flexible sigmoidoscopy every 1-2 years at 12 y/o
If have familial adenomatous polyposis and start to have polyps on colon cancer screening, what is next best step?
colectomy (with new rectum from terminal ileum) b/c adenomas --> cancer all the time by 50 y/o
A pt with hamartomous polyps and melanotic spots (hyperpigmentation of lips, skin, mucosa) presenting with abdominal pain due to intussusception/ bowel obstruction most likely suffers from ...
A pt with CNS tumors and colon cancer most likely suffers from ...
A patient with multiple soft tissue tumors (osteomas of mandible, lipomas, fibrosarcomas) and colon cancer most likely suffers from ...
What are the most common causes of acute pancreatitis?
(pentamidine, 6MP, sulf drugs, azathioprine, hypertriglyceridemia)
What is the initial step in management of severe GI bleed (hypotensive & tachycardiac)?
fluid resuscitation w/ normal saline or lactated ringers
(followed by CBC- hct & plt; PT; type & crossmatch)
When should you transfuse packed RBCs in pt with severe GI bleed?
Hct < 30% if older, heart disease
Hct <25% if younger, healthy
When should you transfuse platelets?
platelets < 50,000 (if surgery or already bleeding)
What is the next best step in management if the PT is elevated in pt with GI bleed?
fresh frozen plasma (immediate)
What are the common causes of lower GI bleed?
2. AVMs (angiodysplasia/ vascular ectasia)
What are diagnostic criteria for orthostatic hypotension?
1. HR >10 or more
2. SBP > 20 or more
(occurs once 15-20% blood loss; used if pt normal when lying down)
If SBP < 100 or HR >100, suggests what amount of blood loss?
30% blood loss
If a pt has hx of liver disease or alcoholism presenting with acute GI bleed, what treatment should be used if vomiting blood?
Octreotide (decreases portal hypertension to help with varices)
If octreotide does not stop bleeding of esophageal varices, what is the next best step of management?
Emergency endoscopy for banding then TIPS (transjugular intrahepatic portosystemic shunting)
What is a common complication of TIPS for varcieal bleeding?
encephalopathy (blood not detoxified by liver)
What is the treatment used for pt who presented with variceal bleeding secondary to portal hypertension but now stable (no active bleed)?
Propanolol (nadolol; beta blocker prevents recurrent bleeding)
A pt with an upper GI bleed with hx of abdominal aortic aneurysm repair in last 6 months most likely suffers from ...
A pt presents with mid-epigastric pain that radiates to the back with tenderness, nausea, vomiting most likely suffers from ...
What is the initial best test for suspected pancreatitis?
amylase and lipase
What is the most accurate test for severity pancreatitis?
CT scan (better than ranson criteria- leukocytosis, LDH, AST, BUN, glucose, hypoxia, hypocalcemia; to determine if surgery)
If CT scan shows severe necrosis of pancreas in pancreatitis, what is the next best step in management?
1. give antibiotics (imipenem)
2. percutaneous needle biopsy
... is blue discoloration around umbilicus due to hemoperitoneum and is a sign of ....
Cullen sign; severe necrotizing pancreatitis
... is bluish purple discoloration of the flanks due to tissue catabolism of hemoglobin and is a sign of ....
Turner's sign; severe necrotizing pancreatitis
What is the best treatment for acute pancreatitis that is not necrotizing?
NPO (bowel rest) and IV fluids
What is a common complication of pancreatitis that occurs withing 2-4 weeks of acute episode?
(drain if enlarging, rupture, pain, fistula formation)
What are signs/symptoms of cirrhosis? (6)
1. hypoalbuminemia (ascites, edema)
2. elevated PT (decrease in clotting factors)
3. spider angiomata, palmar erythema
5. portal hypertension (causes varices)
7. splenomegaly (thrombocytopenia)
What is the treatment for the ascites and edema associated with cirrhosis?
spironolactone (decrease aldosterone effects from intravascular volume depletion)
What is the treatment for the encephalopathy associated with cirrhosis?
lactulose (binds uremic acid and eliminates)
What clotting factors are not made in the liver?
2. von willebrand factor
What is the treatment for prolonged PT in the setting of active bleeding?
fresh frozen plasma
difference between serum-ascites albumin gradient
(high in portal hypertension- low albumin in ascites)
What happens to SAAG in portal hypertension?
high b/c albumin in ascites is low
What happens to SAAG in spontaneous bacterial peritonitis?
What is the diagnostic criteria for spontaneous bacterial peritonitis (SBP)?
1. WBC >500 in ascitic fluid
2. neutrophils >250 in ascitic fluid
What is the treatment of spontaneous bacterial peritonitis (SBP)?
1. cefotaxime (renal metabolized)
2. ceftriaxone (liver metabolized)
(w/ albumin transfusion)
What liver disease is associated with inflammatory bowel disease?
Primary sclerosing cholangitis
A middle-age female presents with pruritis and elevated alkaline phosphatase most likely suffers from ...
primary biliary cirrhosis
What antibodies are associated with primary biliary cirrhosis?
A pt presents with pruritis and elevated alkaline phosphatase and a hx of inflammatory bowel disease most likely suffers from ...
primary sclerosing cholangitis
What is the most accurate test for primary sclerosing cholangits?
ERCP (tortusity and beading of biliary system)
What is the treatment for primary sclerosing cholangitis and primary biliary cirrhosis?
2. urosdeoxycholic acid
What is the initial diagnostic test for chronic hep C?
anti-hep C antibodies
PCR hep C viral load
What is the initial diagnostic test for Wilson's disease?
1. ceruloplasmin (low)
(high urinary copper level)
2. slit lamp exam for kayser fleischer rings
What is the initial diagnostic test for Hemochromatosis?
Iron studies (elevated iron, decreased TIBC, increased ferritin)
A pt with a young non-smoker with emphysema and liver diease most likely suffers from ...
Alpha-1 antitrypsin deficiency
What is the treatment for alpha-1 antitrypsin deficiency?
A pt presenting with liver disease, skin hyperpigmentation, insulin intolerance/ diabetes, and restrictive cardiomyopathy most likely suffers from ....
(liver, heart, pancreas, skin, joints, infertility)
What infections are common in patient with Hemochromatosis?
1. Vibro vulnificus
A pt presents with liver disease, movement disorder and eye problems most likely suffers from ...
(liver, movement due to basal ganglia, Kayser Fleischer rings)
What is the treatment for Hemochromatosis?
What is the treatment for Wilson's disease?
copper chelators (penicillamine, trientine)