Flashcards in GI Deck (160):
What drugs cause medication induced esophagitis?
Abx (tetracyc), Antiinflammatory (NSAID/aspirin), Bisphosphonates, iron/KCL
Tx. esophageal perforation?
ABx and supportive care with surgical repair for significant leakage or systemic inflammatory response.
Diagnosis/Tx of zenker?
Diagnosis-barium swallow/manometry, Tx-open/endoscopic surgery or cricopharyngeal myotomy
Best initial/most accurate Diagnosis of esophageal cancer and treatment?
Best initial: Barium swallow?
Most accurate: Endoscopy w/ biopsy, CT (PET/CT) for staging
Treatment: Resection and chemo/radiation
Diagnosis/Tx of esophageal spasm?
Diagnosis-most accurate-manometry (intermittent peristalsis or mutiple simultaneous contractions) or best initial-esophagram (corkscrew)
Tx-Ca2+ channel blocker (1), nitrates (additional)
Best initial/most accurate for Diagnosis/Management achalasia?
Diagnosis: most accurate-Manometry (increased LES and decreased peristalsis in distal esophagus), best initial-esophagram ("bird beak" at GE Junction)
Management: Upper endoscopy to rule out malignancy. Lap myotomy or pneumatic balloon dilation or botulinum toxin injection, nitrates or CCB
Presentation acute gastritis and cause?
Hematemesis and abdominal pain secondary to acid penetrating lamina propria and injury to vasculature.
Gastric outlet obstruction presentation, findings, diagnosis and management?
>3 hours retained gastric material. "succussion splash" on physical exam with stethoscope over upper abdomen and rocking, endoscopy, and NG suction stomach/IV hydration.
Management acute diverticulitis?
Bowel rest, abx (eg cipro, metro)
Angiodysplasia most common location?
Management for minimal bright red blood per rectum (hematochezia) for various categories: 50 or red flags?
Biopsy presentation celiac disease?
Lymphocyte intraepithelial and flattened villi
Laxative abuse biopsy?
Dark brown discoloration of colon with lymph follicles shining through as pale patches (melanosis coli)
Cause and tx of porcelain gallbladder?
Cause-chronic cholecystitis with tx is cholecystectomy
Management of gallstones w/o symp, w/typical biliary colic, or complicated (cholecystitis, choledocholithiasis, gallstone pancreatitis)
No symp-no tx
Biliary colic-elective lap chole or ursodeoxycholic acid for poor surgical candidates
Chole within 72 hours for complicated
ALT level in gallstone pancreatitis
Managment emphysematous cholecystitis
IV fluids/electrolytes, lap chole, parenteral antibiotic therapy against gram + anaerobic clostridium
Test and Tx. of sphincter of oddi dysfunction?
Test is high biliary sphincter pressure and ERCP with sphincterotomy for tx
Charcot triad and reynolds pentad
Fever, jaundice, RUQ pain; mental status cahnges, hypotension (reynolds pentad)
Imaging/tx for acute cholangitis?
U/S or CT scan shows CBD dilation, increased biliary drainage: ERCP with sphincterotomy or percutaneous transhepatic cholangiography, Broad spectrum ABX (B-lactam/b-lactamase inhibitor, third gen cehalosporin + metronidazole
Liver biopsy and other assoc conditions for primary sclerosing cholangitis?
-Alternating stricture and dilation w/ "beading" of intra/extrahepatic bile ducts.
-Assoc with ulcerative colitis with both having P-ANCA
-Increase risk cholangiocarcinoma and colon cancer as well as cholangitis, cholestasis and cholelithiasis
Triad of hereditary hemochromatosis and diagnosis best initial and accurate?
Bronze skin, micronodular cirrhosis, DM II. Best initial (iron studies showing increased iron and ferritin with decreased TIBC). Liver biopsy for increased iron
Colon cancer MC site of metastases?
Diagnosis of acute pancreatitis requires what?
2 of the following:
1) acute epigastric pain radiating to back
2) Increase amylase/lipase>3 times normal limit
3) Abdominal imaging showing pancreatic enlargement with heterogenous enhancement
Cullen vs Gray turner severe pancreatitis?
Cullen-periumbilical bluish coloration periumbilical indicating hemoperitoneum
Gray-Turner-reddish brown around flanks indicating retroperitoneal bleed
Management chronic pancreatitis?
-Pain management, small meals, alcohol/smoking cessation, pancreatic enzyme supplements
Most important risk factor pancreatic adenocarcinoma?
Conditions with mainly conjugated and elevated AST/ALT?
Variety of hepatitis (viral, ischemic, alcoholic, autoimmune etc.)
Signs/symptoms of carcinoid?
Skin-flushing, GI-diarrhea/cramping, Cardiac-valvular lesions (rt>left), Pulmonary-bronchospasm, niacin deficiency w/tryptophan depletion for making serotonin
Octreotide for symptomatic and surgery for liver mets
What is shock liver?
Ischemic hepatic injury with AST/ALT elevation (the thousands) short after septic shock or heart failure
Management for cirrhosis with imagin
Screening endoscopy and ultrasound surveillance for HCC every 6 months
Prophylaxis for variceal hemorrhage?
Non selective B-blockers
What is hepatorenal syndrome?
decrease GFR in absence of shock, proteinuria, or other clear causes of renal dysfunction, and failure to respond to 1.5L NS bolus (resuscitation) as a complicaton of cirrohosis
Type 1 vs Type 2 Crigler Najjar?
Type I->25-30 bilirubin, kernicterus, no phenobartital help, tx. w/ plasmapharesis/phototherapy w/ liver transplant definitive
Ascites fluid color and disease: bloody, milky, turbid, or straw color?
Bloody-Malignancy, trauma, TB
Straw-likely more benign
Total protein>2.5 (high protein ascites) and
>2.5-CHF, constrictive pericarditis, peritoneal carcinomatosis, TB, Budd-Chiari syndrome, fungal (eg coccidiomycosis)
SAAG >1.1 and SAAG
>1.1 (indicates portal hypertension)-cardiac ascites, cirrhosis, Budd-Chiari
SBP presentation and diagnosis and tx?
Presentation->100F, abdominal pain/tenderness, alterned mentation
Diagnosis->250 neutrophil (best initial) w/ fluid culture (most accurate but takes too long)
Tx. E. coli (cefotaxime or ceftriaxone) w norfloxacin or TMPSMX for prophylaxis
Diagnosis and tx for small intestinal bacterial overgrowth?
Diagnosis-Endoscopy w/ jejunal aspiration, glucose breath hydrogen testing
Tx-7-10 day course of ABX (eg rifamixin, amoxicillin-clavulonate), avoid antimotility like narcotics, dietary changes (eg high fat, low carb), triad of promotility agents (eg metoclopramide)
Diagnosis of colovesical fistula?
Abdominal CT with oral or rectal contrast (contrast material in bladder and thickened colonic and vesicular walls)
Rome diagnostic criteria for IBS?
>3 days/month for past 3 month of abdominal pain/discomfort and 2 of following: Symptom improvement with BM, change in frequency of stool, change in form of stool.
Hallmark of UC?
Tx of toxic megacolon?
IV steroids, NG decompression, antibiotics (ceftriaxone and metronidazole), and fluid management
Best initial/most accurate test SCC of neck
Best initial-panendoscopy (triple endoscopy-esophagoscopy, bronchoscopy, laryngoscopy)
Most accurate-biopsy when primary tumor is detected
Hallmark of crohn disease?
Epigastric pain, tenderness, and possible occult blood nausea and vomiting
Tx of PUD perforation?
Abx (ceftriaxone, metranidazole) and laparotomy with repair of perforation.
What causes achlorhydria?
Pernicious anemia (autoimmune destruction of parietal cells)
Imaging studies to localize GI bleed?
Radionuclide=slow/intermittent; Angiography=more rapid bleeds. Capsule when upper/lower endoscopy show no etiology
How do you diagnose diverticulitis and what do all patients need after treated episode?
CT abdomen with contrast. Colonoscopy after (because colon cancer with perforation can mimic diverticulitis clinically and on CT)
What is osmotic diarrhea?
Nonabsorbable solutes that remain in the bowel and attract water (eg lactose)
What is secretory diarrhea?
Too much fluid secretion by bowel. Occurs with cholera, VIPoma, and in ileal resection when can't reabsorb bile salts
Common cause of malabsorptive diarrhea?
Infectious diarrhea clues?
Fever and WBC in stool (invasive bacteria such as Shigella, Salmonella, Yersinia, and Campylobacter)
Infectious diarrhea tx
What is exudative diarrhea?
Inflammation of bowel causing seepage of fluid commonly seen in IBD where WBC in stool and fever, but lack pathogenic organisms.
What pericpitates toxic megacolon?
What is HBcAb
IgM hepatitis B core antibody appears in window phase when both HBsAg and HbsAb are negative.
Tx acute hep B exposure?
Hep B Ig and Hep B vaccination
Tx acute hepatitis C
Pegylated interferon alfa and ribavirin and either telaprevir or boceprevir
What population is hepatitis E fatal in?
Tx of autoimmune hepatitis
Steroids or azathioprine
Labs of wilson disease?
Low serum ceruloplasmin
Two common causes of cholestasis?
Medications (eg OCP, TMPSMX, phenothiazines, androgens) and pregnancy
Tx primary biliary cirrhosis?
Cholestyramine with symptoms, but only tx is liver transplantation
Rule about contrast when GI perforation suspected?
For GI studies, barium is preferred. For GI perforation, do not use barium because chemical peritonitis or mediastinitis when perforation/leak is present. Use water soluble (eg Gastrografin).
Identifying physiologic jaundice in newborns based on bilirubin levels?
Full term infants: bilirubin
Difference in etiology from dysphagia from solids-->liquids vs dysphagia (solids+liquids)
tx infectious esophagitis (candida_
Dysphagia w/ CD4
1) Empiric fluconazole
2) Improvement, continue with HAART
3) No improvement, upper endoscopy and if large ulcerations-->CMV (tx. ganciclovir) or small ulcerations-->HSV (tx. acyclovir)
Schatzki Ring vs Plummer Vinson location, association, treatment?
Ring (distal, reflux and hiatal hernia, pneumatic dilation)
PV (proximal, iron deficiency, web, and glossitis, iron replacement)
Most accurate for scleroderma manifestations of GERD?
Tx mallory weiss?
Supportive, severe may need epi to stop bleeding
Pain epigastric pain without any other symptoms?
Best initial/most accurate epigastric pain for tests
Best initial tx for epigastric pain?
Management of Barrett alone (metaplasia), low grade dysplasia, and high-grade dysplasia?
Barrett alone-PPi and rescope every 2-3 years
Low grade dysplasia-PPi and rescope every 6-12 months
High-grade dysplasia-Ablation w/ endoscopy: photodynamic therapy, radiofreq ablation, endoscopic mucosal resection
Gastritis presentation and tx.?
GI bleeding without pain. From mild "coffee ground" emesis, to large-volume vomiting of red blood, to black stool (melena). PPi
H pylori testing most accurate?
Endoscopy with biopsy
Triple therapy for H pylori with or without penicillin allergy?
No allergy-PPi, amoxicillin, clarithromycin
Allergy-PPi, methotrexate, clarithormycin
No response to DU therapy for H pylori
Check antibiotic resistance of organizm with method of detecting persistent infection (urea breath, stool antigen, or repeat endoscopy)
Tx of refractory ulcers to H pylori triple therapy?
GU-endoscopy+biopsy to rule out cancer
DU-switch to metranidazole and tetracycline for amoxicillin
Most accurate test PUD?
Difference btwn GU and DU?
Pain often worsened by food, GU routinely biopsied, GU associated with cancer, routinely repeating endoscopy to confirm healing is standard with GU
No ulcer dyspepsia management 55
55: PPi+ Endoscopy
Best initial/most accurate ZE syndrome?
Most accurate-Secretin response test with persistent high levels of gastrin
Imaging best initial/most accurate once gastrinoma confirmed and tx.?
Best initial-CT/MRI (poor sensitivity)
Most accurate-Somatostatin receptor scintigraphy (nuclear octreotide scan) with endoscopic U/S
Tx. Localized with resection and metastatic is unresectable
Tx diabeteic gastroparesis?
Erythromycin and metoclopramide
->10 point rise in pulse from laying to sitting and >20 SBP drop (indicates 15-20% blood loss)
What indicates 30% blood loss in terms of pulse and BP?
Pulse>100 and BP
Why is NG tube useful for acute bleeding from rectum?
Guide where to start endoscopy
What are current guidelines for keeping Hb>9 g/dL in variceal hemorrhage?
1) PRBC for GI bleed
Tx of bleeding vs nonbleeding varices after hemodynamic support (ie fluids, blood, platelets, and plasma)?
Bleeding: 1) octreotide 2) banding 3) TIPS not controlled by octreotide/banding 4) Propranolol/nadolol for preventing subsequent episodes
Nonbleeding: 1) nonselective B-blockers decrease progression 2) Endoscopic variceal ligation w/ B-blocker contraindication
2 Abx with highest incidence of C diff with best initial test
Clindamycin or ampicillin/C. diff toxin test
Tx of recurrent C diff associated diarrhea?
Tropical sprue vs celiac disease involvement?
Celiac-duodenum (can have iron deficiency)
Tropical-jejunum/ileum (can have B12/folate deficiency)
How do you differentiate chronic pancreatitis and gluten sensitive enteropathy?
Presence of iron deficiency in gluten sensitive enteropathy
Tx. dermatitis herpetiformis
Dapsone and gluten free diet
Most accurate test whipple?
PAS+ of LP in small intestine with foamy macrophages.
Presentation whipple and treatment?
Cardiac, Arthralgias, Neurologic (dementia/seeizures). Tx. ceftriax followed by TMP/SMX
Best initial/most accurate celiac?
Anti-tissue transglutaminase (may be absent with IgA deficiency patient), small bowel biopsy showing flattening of villi (also for whipple and tropic sprue)
What is D-xylose test?
Differentiate malabsorption due to small intestine degradation or pancreatic insufficiency. Degradation NO d-xylose absorption, but pancreatic or lactase insufficiency allow d-xylose absoprtion becaue it is already a simple sugar not needing degradation.
Most accurate test chronic pancreatitis?
Secretin stimulation test
Tx. tropical sprue?
1) Fiber in diet
2) Antispasmodic (hyoscyamine, dicyclomine)
3) TCA (eg amitriptyline or SSRI)
4) Antimotility such as loperamide for diarrhea
When and how often shoul screening occur for IBD?
After 8 to 10 years of COLONIC involvement, with cononoscopy every 1-2 years
ANCA and ASCA with IBD as serology when diagnosis is still unclear.
Most accurate test IBD?
Steroid specific for IBD?
USed to wean patients off steroids in disease so severe recurrences develop as steroids are stopped?
Azathioprine and 6-MP
Chronic maintainence remission?
5 ASA (mesalamine)
Fistulae and severe disease unresponsive to other agens?
Infliximab (anti TNF)
Most accurate test for Diverticulosis?
Best initial test Diverticulitis?
CT scan. Colonoscopy and barium dangerous because of increased risk of perforation where infection weakens colonic wall
1) Cipro and metro OR
2) amox/clavulonate, ticarcillin/clavulonate
Colonoscopy screening with or without family hx?
-With family hx. 10 years before diagnosis or age 40, whatever is younger. If family diagnosed
Options if they dont want colonoscopy?
High sensitivity fecal occulty annually OR flex sig every 5 years combined with FOBT every 3 years
Screening HNPCC (3 fam members, 2 gen, 1 premature (
start at age 25 with every 1-2 years after with colonoscopy.
Lynch syndrome I vs Lynch syndrome II
I-hereditary site specific colon cancer
II-cancer family syndrome. Assoc with endometrial (43%), ovarian, and skin cancers
At 12 yearly with sigmoidoscopy
Previous adenomatous polyp?
Every 3-5 years colonoscopy
Previous history colon cancer screening?
Colonoscopy at 1 yr after resection, then 3 years, then every 5 years
Puetz Jeghers presentaiton?
Multiple hamartomatous polyps in association with melanotic (hyperpigmented) spots on lips and skin. Increased friequency of breast, gonadal, pancreatic, colorectal, stomach cancers
Turcot-FAP and CNS malignancy
Gardner-FAP and osteomas, desmoid, or other soft tissue tumors
Juvenile polyposis syndrome?
Multiple hamartomatous polyps in colon, stomach, small bowel iin children
Best initial and most accurate for acute pancreatitis?
-Amylase and lipase initial, CT scan most accurate
MRCP vs ERCP
MRCP is diagnostic. ERCP for therapy
Type of contrast for abdominal CT scan?
IV and oral contrast
When you use antibiotics in pancreatitis?
>30% necrosis can benefit from imipenem or meropenem to prevent development of infected, necrotic pancreatitis
Hyperestrogen manifestations for chronic liver disease?
2) Palmar erythema
3) Loss of body hair
4) Testicular atrophy
5) Angiomas (spider)
All patients with chronic liver disease should be immunized against what?
Hep A and B
Indications for paracentesis?
new onset ascites, abdominal pain or tenderness, fever
treatment of SBP cases?
Cefotaxime or ceftriaxone. All patients need life long prophylaxis with norfloxacin (fluoroquinolone) or TMP/SMX
What to use if patient not responsive to lactulose in lowering serum ammonia?
Somatostatin (octreotide) or midodrine w/ liver transplant as only established benefit
Primary biliary cirrhosis presentation?
Autoimmune destruction of intrahepatic bile ducts with lymphocytic infiltrate and granulomas
Tx of PBC and PSC?
PBC: Ursodeoxycholic acid, PSC: Ursodeoxycholic or cholestyramine
Most accurate test PBC vs PSC?
PBC biopsy or ANA; PSC is ERCP or MRCP showing beading, narrowing of strictures in biliary
Tx chronic hep B
Any one of following: Adefovir, Lamivudine, Telbivudine, Entecavir, Tenofovir, Interferon
Tx chronic hep C
combination of ledipasvir and sofosbuvir oral (genotype 1) or sofosbuvir and ribavirin (genotype 2 and 3)
Adverse effect interferon
Arthralgias, thrombocytopenia, depression, leukopenia
Adverse effect ribavirin
Adverse effect adefovir
Adverse effect lamivudin
Adverse effect bocepevir
Adverse effect telaprevir
Feature of Wilson disease?
Copper is Hella BAD (Decrease Ceruloplasmin, Cirrhosis, Corneal deposits, Copper accumulation, Carcinoma), Hemolytic anemia, Basal ganglia degeneration, Asterixis, Dementia, Dyskinesia, Dysarthria
Best initial and most accurate for Wilson disease?
Best initial-Slit lamp
Most accurate-increase copper in urine after penicillamine
Indications for pseudocyst drainage?
Secondary infection, >5 cm, >6 weeks, symptomatic
Why gallstones present in females who are pregnant?
Estrogen induced increase in cholesterol secretion underlying mechanisms for cholesterol gallstones. Decreased progesterone means decreased motility and increased stasis predisposing to formation as well
Risk factor acalculous cholecystitis?
Severe trauma, burns, recent surgery, prolonged fasting or TPN, sepsis ICU or mechanical ventilation
Why is T3 and T4 total levels decreased with normal TSH in chronic liver disease?
Decreased TBG production by liver so decreased total T3 and T4 with normal free T3 and T4 levels
Most likely cause of UGI vs LGI bleed?
Drugs that cause pancreatitis (3)?
Azathioprine, valproic acid, thiazides
Most common underlying cause of cirrhosis
Chronic alcohol, hepatitis (C>B), nonalcoholic fatty liver, hemochromatosis
Zinc deficiency features?
Alopecia, abnormal taste, bullous pustulous lesions on body orifices, and impaired wound healing
Extrahepatic manifestation of chronic hep C
Heme-mixed cryoglobulinemia, Renal-membranoprolif glomerulonephritis, Skin-porphyria cutanea tarda, lichen planus, Endocrine-increase risk diabetes