GI

Question 1

Diagnosis of achalasia

Answer 1

Manometry is the most accurate test and will show failure of the LES to relax
Barium esophagram will show a birds beak
Upper endoscopy is useful to rule out malignancy

Question 2

Achalasia treatment

Answer 2

Pneumatic dilation, myomectomy or surgical sectioning is more effective but more dangerous
Botox injections – last 3 to 6 months

Question 3

For cancer, what is never the most accurate test?

Answer 3

Radiologic tests, For example, esophageal cancer needs an endoscopy and biopsy

Question 4

Best test for diffuse esophageal spasm and nutcracker esophagus

Answer 4

Manometry, which will show a different pattern of abnormal contraction and each of them
Corkscrew appearance when spasm is occurring
Treated with CCBs and nitrates, similar to Prinzmetal angina, PPIs can help

Question 5

Dysphagia and HIV patient with CD4 less than 100, what to do next?

Answer 5

Empirically start flucanazole, assuming esophageal candidiasis
If no improvement, upper endoscopy with biopsy and if large ulcerations it’s CMV treat with ganciclovir, if small – HSV, acyclovir

Question 6

How to detect rings and webs

Answer 6

Barium studies of the esophagus

Question 7

Zenker is diagnosed with? Treatment?

Answer 7

Barium studies, surgery

Not NG tube or endoscopy, dangerous for these people they may perforate

Question 8

How to scleroderma present, management?

Answer 8

Reflux, inability to close the LES, manage with PPI’s

Question 9

Manometry for

Answer 9

Achalasia, spasm, Scleroderma

Question 10

Stress ulcer prophylaxis indicated in

Answer 10

Mechanical ventilation, burns, head trauma, coagulopathy

Question 11

Cancer and gastric versus duodenal ulcers

Answer 11

4% of gastric, virtually no duodenal

Question 12

Therapy for H. Pylori

Answer 12

PPI + clarithromycin + amoxicillin
If refractory: metronidazole + tetracycline
If gastric ulcer, repeat ulcer to exclude malignancy
Test of cure: stool antigen or breath test

Question 13

Non ulcer dyspepsia management

Answer 13

If under 45, empiric with PPI
If over 55, endoscopy
Also if dysphagia weight loss, anemia

Question 14

Gastrinoma is often associated with?

Answer 14

Diarrhea since the acid inactivated lipase

Question 15

If gastrinoma + hypercalcemia?

Answer 15

MEN 1: hyperparathyroidism

Question 16

Once gastrinoma confirmed, next best step is to?

Answer 16

Exclude mets: CT/MRI of abdomen, if normal then somatostatin receptor scintigraphy + endoscopic US

Question 17

GIB treatment

Answer 17

IVF
transfuse PRBCs when HCT below 30 in elderly/CAD pts
If drops below 20-25 in others
FFP
platelets if below 50k + bleeding
Varices: Octreotide decreases portal pressure, banding, TIPS, propranolol/nadolol, abx to prevent SBP

Question 18

Treatment for Whipple

Tropical sprue?

Answer 18

Ceftriaxone followed by Bactrim

Tropical sprue: bactrim, tetracycline

Question 19

Distinction between chronicle pancreatitis and celiac

Answer 19

Celiac will have iron deficiency as it requires an intact bowel wall to be absorbed, but does not need pancreatic enzymes
In contrast vitamin B12 needs both

Question 20

Diagnosis of chronic pancreatitis

Answer 20

Abdominal XR, CT

Most accurate: secretin stim test: healthy will release large volume HCO3- rich fluid

Question 21

IBS treatment

Answer 21

Hyocyamine, Diclocyamine

TCAs, loperamide, lubiprostone, linaclotide

Question 22

Treatment of IBD

Answer 22

5-ASA agent: mesalamine
Azathioprine, 6-MP to wean of steroids
Calcium, vitamin D
Perianal Crohns: cipro and metro
Anti-TNF: infliximab if severe
Surgery especially for UC

Question 23

Diverticulitis treatment

Answer 23

Cipro + Flagyl
Augmentin
Zosyn
Timentin
Carbapenem
NPO
Surgery if no response, recurrent infections, perforation, abscess, fistula, obstruction

Question 24

HNPCC screening

FAP?

Answer 24

Begin at 25, scope every 1-2 yrs

FAP: sigmoidoscopy at 12 every year

Question 25

paracentesis should be performed if?

Answer 25

new-onset ascites, abdominal pain/tenderness, fever

Question 26

SAAG over 1.1

Answer 26

think "dilute" ascites fluid- pushed out: portal HTN, CHF, hepatic vein thrombosis, constrictive pericarditis

Question 27

SAAG less than 1.1

Answer 27

think leakage ("exudate" like): infections (except SBP), cancer, nephrotic syndrome?

Question 28

MC etiologies of SBP | treatment

Answer 28

E. coli, S. pneumo, NOT anaerobes treat with cefotaxime or ceftriaxone frequently recur, prophylax with norfloxacin or bacterium if low albumin in ascites all variceal bleeding with ascites needs SBP ppx

Question 29

treatment of hepatorenal syndrome

Answer 29

somatostatin (octreotide), midodrine

Question 30

when to think hepatopulmonary syndrome

Answer 30

orthodexia | hypoxia with sitting upright

Question 31

normal bilirubin with elevated alk phos, xanthomas, osteoporosis, think? how to diagnose? tx?

Answer 31

PBC most accurate test is liver biopsy, most accurate blood test: AMA Ab bilirubin and IgM levels elevate LATER treat with urso

Question 32

IBD, pruiritis, ^alk phose, GGTP, bilirubin, think? | most accurate test?

Answer 32

PSC MRCP*/ERCP(generally don't need intervention) is best test, shows narrowing/beading/strictures in biliary system biopsy not needed (only cause of cirrhosis that does not need biopsy) treat with urso or cholestyramine, does NOT improve with IBD resolution (colectomy)

Question 33

mild ^AST, Alk phos, fatigue, joint pain, ED, amenorrhea, skin darkening, DM, cardiomyopathy, think? what infections are more common? dx?

Answer 33

hemochromatosis pituitary involvement- amenorrhea/ED infections with Vibrio vulnificus, Yersina, Listeria (feed on iron) dx liver biopsy after ^iron/ferritin, but abdominal MRI and HFE (C282y) genetic testing may spare need for liver biopsy EKG may show condition defects, echo CM

Question 34

hemochromatosis treatment

Answer 34

phlebotomy if are refractory or are anemic and have hemochromatosis from over transfusion (thalassemia), iron chelation therapy: deferoxamine (IV/IM), deferasirox, deferiprone (oral)

Question 35

treatment for hepatitis B

Answer 35

any 1 of the following: (combo tx is not more effective) | adefovir, lamivudine, telbivudine, entecavir, tenofovir, interferon

Question 36

treatment of hepatitis C

Answer 36

acute: interferon, ribavirin, and either telaprevier or boceprevir chronic: combo of ledipasvir and sofosbuvir (genotype 1) sofosbuvr and ribavirin (genotypes 2, 3) + interferon, ribavirin, boceprevir when treatment fails combo therapy is best, follow with PCR viral load

Question 37

cirrhosis, hepatic insufficiency, psychosis, tremor, ataxia, seizures, coombs negative hemolytic anemia, RTA or nephrolithiasis, think?

Answer 37

Wilsons best initial test: slit lamp for Kayser-Fleischer rings LOW ceruloplasmin liver biopsy shows ^copper most accurate test: abnormally increased copper excretion AFTER penicillamine (chelates) other tx: Zn: interferes with absorption, trientine: chelates

Question 38

autoimmune hepatitis markers

Answer 38

+ANA, +anti-liver-kidney microsomal Abs, ^IgG, +anti-smooth muscle Abs treat with prednisone +/- azathioprine