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GI Flashcards

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1
Q

Tx: Cholelithiasis in non-surgical candidate

A

Ursodeoxycholic Acid

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2
Q

Dx: Cholecystitis

A
  • RUQ U/S
  • If equivocal = HIDA
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3
Q

Tx: Cholecystitis in non-surgical candidate

A

Cholecystostomy

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4
Q

Dx: Choledocholithiasis

A
  • RUQ U/S
  • MRCP
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5
Q

Tx: Choledocholithiasis

A
  1. IVF, NPO, IV Abx
  2. Urgent ERCP or Cholecystectomy with intraoperative cholangiogram
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6
Q

Dx: Cholangitis

A
  • RUQ U/S
  • Clinical
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7
Q

Tx: Cholangitis

A
  1. IVF, NPO, IV Abx
  2. Emergent ERCP or Cholecystectomy with intraoperative cholangiogram
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8
Q

Abx used in cholangitis

A
  • Cipro + Metronidazole
  • Amp/Gent + Metronidazole
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9
Q

Tx: Pill-induced Esophagitis

A
  • EGD to remove pill
  • PPI
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10
Q

Tx: Infectious Esophagitis

A
  • Candida = Fluconazole
  • HSV = (val)acyclovir
  • CMV = (Val)gancyclovir
  • HIV = HAART (b/c this is AIDS-defining illness)
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11
Q

Tx: Eosinophilic Esophagitis

A
  • 1st: PPI (b/c GERD can cause eosinophilia)
  • 2nd or if already on PPI: oral aerosolized steroids (Budesonide)
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12
Q

Tx: Caustic Esophagitis

A
  • If (+) Stridor = intubate ppx
  • Low severity = NPO then liquids at 24 hr
  • High severity = NPO x 72 hours; then f/u EGD to determine if safe for escalation, presence of strictures
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13
Q

Drugs most likely to cause Pill-induced Esophagitis

A
  • NSAIDs
  • Abx: Doxycycline (tricyclics); TMP-SMX (Bactrim), Clindamycin
  • Anti-retrovirals (NRTIs)
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14
Q

Histology of Barrett’s Esophagus

A

Metaplasia from smooth mm of the distal esophagus to columnar epithelium (similar to small intestine)

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15
Q

Ppx in pt w/ PUD who cannot stop NSAIDs

A

**PPI**

If can’t take PPI, Misoprostol

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16
Q

PUD + Persistent Diarrhea

Next step?

A

Serum Gastrin Level

  • >1600 = Zollinger-Ellison
  • 250-1600 = Secretin Stim Test
    • Increased Gastrin = ZE
  • < 250 = Ruled out
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17
Q

Positive for ZE Syndrome. Next step?

A

Somatostatin Scintigraphy to localize tumor

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18
Q

Suspect H. pylori. Next step?

A
  • Never been treated before = serology
  • Treated before = Urea breath test
    • Must be off PPI
  • Best test: EGD + Bx
    • Get Histology
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19
Q

Test for eradication of H. pylori

A

Stool Ag

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20
Q

Triple Therapy

A

“CAP that H. pylori ulcer”

  • Clarithromycin
  • Ampicillin
    • Metronidazole if Penicillin-allergic
  • PPI
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21
Q

Tx: Gastroparesis

A
  • Acute
    • IV Erythromycin
  • Chronic
    • PO Metoclopramide
  • Diabetes control
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22
Q

Drugs Contra in Gastroparesis

A
  • Opiates
  • Anticholinergics
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23
Q

Dx: Gastroparesis

A
  • EGD to rule out other dz
  • Nuclear Emptying Study
    • must stop opiates and anticholinergics. Good glucose control.
    • >60% at 2 hours = (+)
    • >10% at 4 hours = (+)
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24
Q

Enlarged lymph node in left supraclavicular fossa indicates?

A

Gastric Cancer

(called Virchow’s Node)

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25
Tx: Gastric cancer, Bx shows lymphoma
MALToma Tx: Triple Therapy
26
Tx: Gastric cancer, Bx shows signet ring cells
Gastric Adenocarcinoma Tx: Stage w/ PET-CT; Resection and Chemo
27
Risk factors for Gastric Adenocarcinoma
Diet rich in Nitrites (smoked fish) Usually E. Asian
28
Etiology & Tx of Cyclic Vomiting Syndrome
* Ethiology * THC * Tx: * Stop THC * Metoclopramide * Erythromycin
29
Side effects limiting Metoclopramide use in Gastroparesis
Tardive Dyskinesia
30
Most sensitive test for invasive bacteria
Lactoferrin
31
Best test for C. diff
C. diff NAAT
32
Tx: repeated recurrences of C. diff
Fidaxomicin
33
Bloody diarrhea + Low Hgb + Elevated Cr. Next step?
HUS * Dx: * serum shiga toxin * E. coli O157:H7 culture * Tx: Plasma exchange, supportive
34
Work-up for chronic diarrhea
* Stool Osmolar Gap * Measured Osm (290) - Calculated Osm ((Na + K)\*2) * \< 50 = Secretory * \>100 = Osmotic * Fecal WBC * FOBT * Fecal Fat * NPO
35
Pt w/ diarrhea has an osmotic gap of 110, increased fecal fat, and decreased diarrhea w/NPO. Dx?
Osmotic Diarrhea | (likely malabsorption)
36
Pt w/ diarrhea has a normal osmotic gap, normal fecal fat, no fecal blood cells, and no change with NPO. Dx?
Secretory Diarrhea
37
Dx and next step: Secretory Diarrhea + refractory ulcers
Gastrinoma * Serum gastrin * \<350 = r/o * \>1600 = r/i * in between = secretory stimulation test * If r/i * Somatostatin Receptor Scintillography (SRS)
38
Dx and Next Step: Secretory Diarrhea + flushing + heart problems
Carcinoid metastasized to liver * Dx * Urinarry 5-HIAA to confirm
39
Dx and Next Step: Secretory Diarrhea + Pancreatic Mass
VIPoma * Dx: * High serum VIP
40
Pt w/ diarrhea has blood cells and mucus in stool
Inflammatory Diarrhea
41
Dx: Positive anti-endomysial and tissue transglutaminase abs
Celiac Disease
42
Dx & Tx: Picture of celiac dz but in a Carribean farmer
Tropical Sprue * Dx: * Abs = negative * EGD + Bx = villous blunting * Tx: * Abx: TMP-SMX (Bactrim)
43
Pt has the rash shown on extensor surfaces and the buttocks. Next step?
* Dx * Antibodies: * best: anti-tissue transglutaminase * anti-endomysial * If Ab negative but strong suspicion = EGD + Bx
44
Pt has elevated fecal fat, suspicious of malabsorption diarrhea. What is the next diagnostic step?
D-Xylose + CT scan * Absorbed = Pancreatic Deficiency * Tx: Supplement pancreatic enzymes * Not absorbed = Intestinal Border Deficiency * Dx: EGD + Bx
45
Dx: Pt has malabsorption diarrhea with brain/lymph/joint problems.
Whipple Disease * Dx: * EGD Bx * Light microscopy = PAS+ Microphages * Electron microscopy = see organisms * PCR of blood/CSF
46
Tx: Pt w/ Osmotic diarrhea, PAS+ Macrophages on light microscopy
Long-term Abx * TMP-SMX (Bactrim) * Doxycycline
47
Pt is a middle-aged woman with normal periods, iron-deficiency anemia, and osteoporosis. Next step?
Look for Celiac Sprue (Malabsorption at proximal duodenum of FIC - Folate, Iron, Calcium) * Dx: * Abs (anti-tTG or anti-endomysial) * If negative, EGD + Bx
48
Tx: Mild Ulcerative Colitis
5-ASA compounds * Mesalamine * Sulfasalazine
49
Tx: Moderate Ulcerative Colitis
Immune Modulators * 6-MP * Azathioprine * MTX (last resort)
50
Tx: Ulcerative Colitis Flare
1. Rule out C. diff (NAAT) 2. Steroid (Prednisone) + Abx (Cipro + MTZ)
51
Tx: Severe Ulcerative Colitis
Resection
52
Tx: Mild Crohn's Dz
Can try 5-ASA compounds * Mesalamine * Sulfasalazine
53
Tx: Moderate Crohn's Dz
Immune Modulators * 6-MP * Azathioprine * MTX (last resort)
54
Tx: Crohn's Dz Flare
1. Rule out C. diff 2. Steroids (Prednisone) + Abx (Cipro + MTZ)
55
Tx: Severe Crohn's Dz
TNF-alpha inhibitors * Infliximab
56
Tx: Diverticulitis
1. Bowel rest 2. Abx * Cipro + MTZ * Amp/Gent + MTZ
57
Pt w/ "left-sided appendicitis." Next step?
1. PA (upright) CXR to rule out perforation of possible diverticulitis 2. CT scan - diagnose and determine extent of disease
58
When should colonoscopy be performed in diverticulitis?
2-6 wks post-diverticulitis to screen for cancer
59
Dx: Diverticular hemorrhage
1. Tx like GI bleed * 2 large bore IVs * IVF * Type and cross * IV PPI 2. Rule out upper GI bleed * NG tube + EGD 3. Find bleed * Fast bleed = angiogram (with embolization) * Slow bleed = tagged RBC * Stopped bleeding = colonoscopy
60
Tx: Colon cancer
* No spread (stage I/II) = resection * Stage III/IV * FOLFOX * 5-Fu * Leucovorin * Oxaliplatin * FOLFIRI * Add Bevacizumab (VEGF-i)\*\*\*
61
Mutation in FAP
APC gene mutation
62
Mutation in HNPCC
DNA mismatch repair
63
Types of cancers in HNPCC
HNPCC = Lynch Sydrome Think Meryl Lynch, CEO * Colon * Endometrial * Ovarian
64
Colon cancer + brain tumor
Turcot Syndrome
65
Colon Cancer + Osteochondroma of the jaw
Gardner's Syndrome
66
Colon polyps + macules in/around mouth
Peutz-Jeghers Look for small intestinal hamartomas No colon cancer
67
Dx: Pancreatitis
* Lipase \> 3x ULN (best) * Amylase \> 3x ULN * If stones suspected: RUQ U/S -\> ERCP * Symptoms present, but enzymes not elevated * CT scan
68
Tx: Gallstone Pancreatitis
ERCP
69
Etiology Pancreatitis
Most common: Gallstones, EtOH PANCREATITS * Parathyroid hormone * Alcohol * Neoplasia * Calcium * Rocks (gallstones) * Estrogens * ACE-i * Triglycerides * Infarction (ischemia) * Trauma (ERCP, MVA) * Infection (mumps) * Scorpion stings
70
Acute pancreatitis diagnosed in last couple days + hypoTN. Dx and management?
Necrotizing Pancreatitis * Dx: * CT scan = necrosis * Biopsy (required before giving Abx) * Tx: * Meropenem
71
Hx of Acute pancreatitis + Early satiety + Abdominal fullness. Dx and managment?
Pancreatic Pseudocyst * Dx: * CT Scan * Tx: 6&6 Rule * \< 6 cm & \< 6 weeks = observe * \> 6 cm or \> 6 weeks = drain + bx (r/o cancer)
72
Treatment of Pleural Effusion or Ascites associated with Pancreatitis
Do not tap/put in chest tube UNLESS Infected
73
Suspect Wilson's Disease. Next best step?
Slit lamp looking for Kaiser-Fleischer Rings * Other Options * Ceruloplasmin = low * Urine Copper = high * Best = Bx = high Cu
74
Bronze Diabetes suspected. Next best step?
Ferritin level = very elevated (\>1,000) * Other options: * Transferrin \> 50% (better) * Bx = elevated iron (best)
75
Alpha 1 Anti-Tripsin Def suspected. Next best step?
Bx = PAS + Macrophages Best: Phenotyping (PiZZ worst; PiMM normal)
76
PSC suspected. Next best step?
MRCP = beads on a string If bx obtained = onion skinning fibrosis
77
Tx PSC
Symptomatic Relief: Cholestyramine, Ursodeoxycholic Acid (?) Transplant (can recur)
78
PBC Suspected. Next best step?
Serology = AMA + Bx
79
Tx PBC
* First: Ursodeoxycholic acid * Think Ursela from the little mermaid * Transplant (curative)
80
Woman with cirrhosis. AST and ALT in the 1000s. Dx and best next step?
Autoimmune Hepatitis * Dx: * Serology * Anti Smooth Muscle Ab * Anti LKM Ab * Best = Biopsy
81
Tx Autoimmune Hepatitis
Steroids, then transplant
82
AST and ALT in the 1,000s in setting of cirrhosis. Dx?
1. Autoimmune Hepatitis 2. Acetaminophen toxicity 3. Aflatoxin 4. Acute Viral Hepatitis (A,B) 5. Shock Liver (hypoTN) 6. Budd Chiari
83
Dx: Cirrhosis
1. RUQ U/S (to ID cirrhosis) 2. CT/MRI (evaluate for nodules or masses) 3. Biopsy, transjugular (best test)
84
Screening for HCC in Cirrhotic Pts
AFP and RUQ U/S q6mo
85
Vaccinations Needed in Cirrhotic Pts as Ppx
Hep A and Hep B
86
Dx: SBP
Paracentesis with gram stain and culture Dx: \>250 PMNs + 1 organism seen
87
Tx: SBP
Ceftriaxone (3rd gen cephalosporins) or Cipro (Fluoroquinolones)
88
Ppx against SBP
Give FQ qWeek if: 1. Hx of SBP 2. TP \< 1.0
89
Dx: Secondary Bacterial Peritonitis
* Paracentesis with gram stain and culture * \>250 PMNs * At least 2 organisms seen
90
Tx: Secondary Bacterial Peritonitis
* Tx: * MTZ + CTX * Ex-Lap to find perforated bowel
91
Pt with cirrhosis has platypnea. Dx?
Hepatopulmonary syndrome * Dx: 2D ECHO with Bubble Study * (+) if reveals bubbles every 3-6 beats Platypnea (opposite of orthopnea) Path: Vasodilation of pulm artery creates functional R-\>L shunt Tx: Transplant
92
Cirrhosis + Renal Failure in absence of definitive cause. Dx and Tx?
Hepatorenal Syndrome * Dx: * rule out other causes of renal failure * Tx: * Hold diuretics * Give Albumin * Give Octreotide
93
Dx and Tx: Hepatic Encephalopathy
* Dx * Clinical * (don't get ammonia levels!!) * Tx: * Lactulose * Rifaximin + Zinc
94
Confirmatory test for HCC?
Triple-Phase CT
95
Tx: HCC
Resection Transplant Radiofrequency Ablation or Chemo Embolization
96
Tx: Esophageal Varices that are currently bleeding
* EGD + Banding * Octreotide + CTX
97
Asx Jaundice with stress but no dark urine
Unconjugated hyperbilirubinemia Likely Gilbert's as Crigler-Najjar is fatal early in life
98
Asx jaundice with stress + dark urine
C Dr. Rogers Conjugated Hyperbilirubinemia Dubin-Johnson (Dubin = Dark Black Liver on inspection) Rotors Syndrome
99
Dx and Tx: Biliary Stricture
* Dx: * U/S may show dilation * MRCP - diagnose * ERCP + bx - confirm stricture, no cancer * Tx: * Stent
100
Postexposure Ppx for Hep A
IgG + Vaccine w/i 2 weeks of exposure
101
Tx: Hepatitis B
peg IFN-alpha-2a + antivirals (-fovir, -cavir, -vudine) Antivirals: adefovir, entecavir, lamivudine, telbivudine
102
Screening for HCC in Hep B
Screen with U/S and AFP even without cirrhosis
103
Tx: Hepatitis C
* Genotypes 1 & 4 * Interferon + Ribavirin * S/E include psychosis, depression, flu-like symptoms * Genotypes 2 & 3 * Direct Acting Antagonists (protease-inhibitors) = -vir * Ex: borceprovir
104
Screening for HCC in Hep C
No need unless patient is cirrhotic

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