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GI Flashcards

PANRE

1
Q

Which of the following tumor markers is useful in monitoring a patient for recurrence of colorectal cancer after surgical resection?

A

Carcinoembryonic antigen-an be used to monitor a patient for the return of colorectal cancer after treatment.

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2
Q

A patient develops abdominal cramps and watery diarrhea 10 to 12 hours after eating a plate of unrefrigerated meat and vegetables. The patient denies vomiting. The causative agent is most likely

A

Food poisoning caused by Clostridium perfringens has an incubation period of 6 to 24 hours and results from poorly refrigerated cooked meat.

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3
Q

The most common initial presenting symptom of primary biliary cirrhosis is

A

Pruritus is the most common initial symptom in primary biliary cirrhosis due to the accumulation of bile salts.

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4
Q

Which of the following is the therapy of choice for long-term management of esophageal varices in a patient who cannot tolerate beta blocker therapy?

A

Sclerotherapy is effective in decreasing the risk for rebleeding in a patient with esophageal varices.

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5
Q

Initial pharmacologic treatment of acute hepatic encephalopathy consists of

A

Lactulose acts as an osmotic laxative decreasing ammonia absorption and decreases ammonia production by directly affecting bacterial metabolism.

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6
Q

A 72 year-old male presents to the ED complaining of acute onset of severe diffuse abdominal pain of four hours duration. He states that he has vomited twice since the onset of pain. He also complains of three days of constipation. He is afebrile and the physical examination is noteworthy for a distended, diffusely tender abdomen with normoactive bowel sounds. His rectal exam reveals hemoccult positive brown stool.Medications include omeprazole (Prilosec) for GERD, digoxin and warfarin (Coumadin) for atrial fibrillation,OTC multivitamins and stool softeners. The abdominal and chest x-rays show no abnormalities. Which of the following is the most likely diagnosis?

A

Mesenteric infarction

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7
Q

Which medication is considered the mainstay of therapy for mild to moderate inflammatory bowel disease?

A

Question 12 Explanation: Sulfasalazine and other 5-aminosalicylic acid drugs are the cornerstone of therapy in mild to moderate inflammatory bowel disease as they have both anti-inflammatory and antibacterial properties.

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8
Q

Congenital absence of ganglionic nerve cells innervating the bowel wall is seen in which of the following conditions?

A

Hirschsprung disease, also termed congenital aganglionic megacolon, results from a lack of ganglion cells in the bowel wall.

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9
Q

A middle-aged patient is being treated for recurrent diarrhea and peptic ulcer disease that is refractory adequate standard therapy. Which of the following is the most likely diagnosis?

A

Zollinger-Ellison syndrome is the result of unregulated release of gastrin resulting in gastric acid hypersecretion. Up to 50% of patients complain of diarrhea along with peptic ulcer disease.

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10
Q

Which of the following is suggestive of thiamine deficiency?

A

Ataxia, mental deficits, horizontal nystagmus, muscle weakness and atrophy, and cardiomegaly are all clinical findings in thiamine deficiency

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11
Q

Which of the following would be consistent for a person who has a successful response to the hepatitis B immunization series?

A

HBsAg negative; anti-HBc negative; anti-HBs positive

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12
Q

Which of the following presents the greatest risk factor for the development of pancreatic cance

A

igarette smoking is the most consistent risk factor for the development of pancreatic cancer.

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13
Q

The parents of a 16 year-old male presents to the clinic with their son asking that you examine him. Over the past 9-12 months he has developed behavioral problems and emotional lability. Physical examination reveals a well-developed male who is cooperative with exam but tends to be easily distracted. It is noteworthy for dysarthria, a resting tremor and the presence of gray-green pigmentation surrounding each pupil. The most likely diagnosis is

A

Wilson’s disease results in the excessive deposition of copper in the liver and brain. Kayser-Fleisher rings are the result of granular deposits in the eye and are pathognomonic for Wilson’s disease.

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14
Q

Causes of Acute hepatitis (Level 1)

A

Most common causes are viruses and drugs (acetaminophen, alcohol, INH)

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15
Q

S/S of Acute hepatitis (Level 1)

A

S/S:
○ Prodromal phase: Malaise, fatigue, anorexia, N/V, abd pain, joint pain, HA
○ Icteric phase: Jaundice

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16
Q

DX of Acute hepatitis (Level 1)

A

↑ ALT > ↑ AST, both > 500, ±↑ bilirubin

○ Alcoholic hepatitis AST/ALT >2

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17
Q

Hepatitis A -s/s (buzz word)

A

Associated with spiking fever

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18
Q

DX of Hep A

A

Acute: + IgM HAV Ab

○ Past exposure: + IgG HAV Ab with neg IgM

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19
Q

Prevention of HEP A

A

Hep A vaccine for high risk population

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20
Q

+ HBsAg

A

1st evidence of infection before symptoms

■ If stays positive > 6mo → chronic infection

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21
Q

+ HBsAb

A

Indicates immunity

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22
Q

+ HBcAb

A

IgM = acute infection, 1st Ab to appear

■ IgG = prior or current infection

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23
Q

+ HBeAg

A

Indicates ↑ viral replication and infectivity

■ Important indicator of transmissibility (“BE”ware!)

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24
Q

+ HBeAb

A

Waning viral replication and infectivity

■ Low transmissibility

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25
Prevention of Hep B
Hep B vaccine x 3 doses as infant, contraindicated if allergic to Baker’s yeast
26
CI of Hep B
allergic Baker Yeast
27
Hepatitis C transmission
Parenteral (IV drug users, blood transfusions before 1992)
28
Hepatitis C DX
HCV RNA more sensitive than HCV Ab
29
Porcelain gallbladder considered
Premalignant-associated with chronic cholecystitis and gallbladder
30
Acute acalculous cholecystitis
Seen in the acutely ill 2º to dehydration, prolonged fasting, TPN ● Due to gallbladder sludge, not stones
31
Acute Hep almost always converts to chronic true or false?
True; may eventually progress to cirrhosis and liver failure
32
Which hepatitis is only DNA virus?
Hep B ; blood borne,
33
Hep D is always associated with ?
Hep B
34
Treatment for Hep B?
Interferon-alpha, Lamivudine, vaccinatinos for A and flu yearly and void Etoh
35
Increase risk for primary hepatocellar carcinoma ?
Hep C
36
Chronic can be asymptomatic for years?
Hep C
37
High infant mortality rate in pregnant woman?
Hep E; fecal oral and self limiting dz
38
What is Fulminant Hepatitis ?
Rapid liver failure + encephalopathy | ● Acute w/in 8 weeks of liver injury onset
39
Number cause for fulminant hepatitis ?
``` #1 cause acetaminophen; drug reactions (isoniazid, rifampin), viral hepatitis, Reye syndrome (#1 in kids associated with asa use in viral illnesses), ```
40
s/s fulminant hepatitis ?
S/S: Encephalopathy, vomiting, asterixis, hyperreflexia, coagulopathy, jaundice
41
Dx fulminant hepatitis ?
Dx: ↑ ammonia, ↑PT/INR, hypoglycemia, ↑LFTs
42
TX fulminant hepatitis ?
Tx: Lactulose for hepatic encephalopathy, liver transplant is definitive
43
Acute cholecystitis culprits ?
Gram neg enteric bacteria ( E. coli, Klebsiella, Enterobacter
44
Acute cholecystitis PE?
Fever, + Murphy’s sign, + Boas’ sign (R shoulder pain d/t phrenic nerve irritation)
45
Acute cholecystitis #1 dx imaging?
U/S Distended gallbladder, gallstones, + sonographic Murphy’s sign; HIDA scan if U/S equivocal
46
Acute cholecystitis dx labs?
↑WBC, ↑bilirubin, ↑Alk phos
47
Hida Scan /PIPIDA -Nuclear scan of gall bladder negative test? positive test?
Negative test-GB lights up =can make sx elective; Positive-GB not seen =SX
48
Acute cholecystitis tx?
NPO, IV fluids, antibiotics, cholecystectomy | ○ Ceftriaxone + metronidazole, piperacillin/tazobactam
49
Acute causes for pancreatitis? In Kids?
Causes: #1 gallstones (40%) and #2 alcohol (35%); medications, iatrogenic d/t ERCP, malignancy, scorpion bite, cystic fibrosis, MUMPS IN KIDS
50
S/S of Acute pancreatitis?
Epigastric pain: Constant, boring, radiating to back, relieved by leaning forward ○ N/V ○ Fever
51
PE of Acute pancreatitis?
PE: ± epigastric tenderness, tachycardia, ↓ bowel sounds ■ If necrotizing, hemorrhagic: Cullen’s sign (periumbilical ecchymosis) Grey Turner sign (flank ecchymosis)
52
What criteria is used to dx Acute pancreatitis?
RAnson's criteria can be used for prognosis
53
Labs for Acute pancreatitis?
Lipase: More specific than amylase, rises first and elevated longer as compared to amylase ■ Amylase: >3x upper limit of normal (ULN) suggestive but not as specific ■ ALT: >3x ↑ suggestive of gallstone pancreatitis ■ ↑WBC, ↑glucose, ↑bilirubin, ↑triglycerides ■ Hypocalcemia
54
DX test of choice for Acute pancreatitis?
CT *diagnostic test of choice
55
TX for Acute pancreatitis?
90% recover without complications and only require “pancreas rest” ○ Supportive: IV fluids, NPO, pain control ○ Abx not routinely used; if severe/necrotizing use broad spectrum
56
What is Chronic pancreatitis?
Chronic inflammation causing parenchymal destruction and fibrosis which results in loss of exocrine and sometimes even endocrine function
57
What is Ranson's Criteria?
``` At admission, score ≥ 3 = severe pancreatitis likely ○ Age > 55yr ○ Glucose > 200 mg/dL ○ LDH > 350 IU/L ○ AST > 250 IU/dL ○ WBC > 16,000 ● At 48 hours, combined with the admission 5 suggestive of mortality (score >4 significantly increased mortality: 5 to 6 (40%); 7 to 8 (100%)) ○ Calcium <8.0 mg/dL ○ Hematocrit fall > 10% ○ Oxygen PO2 < 60 mmHg ○ BUN > 5 mg/dL after IV fluids ○ Base deficit >4 mEq/L ○ Sequestration of fluid > 6L ```
58
Causes of Chronic Pancreatitis in adults ?
Causes: #1 alcohol abuse, idiopathic, familial, hyperlipidemia
59
Causes of Chronic Pancreatitis in kids ?
cystic fibrosis #1 in | kids
60
Triad of calcifications, steatorrhea, DM; also weight loss
Chronic Pancreatitis
61
chain of lakes” on CT and calcified pancreas?
Chronic Pancreatitis
62
TX for Chronic Pancreatitis
Oral pancreatic enzyme replacement, pain control, alcohol abstinence
63
Anal abscess/fistula (Level 1) culprits?
Staph aureus, E. coli, Bacteroides
64
Anal fistula?
open tract, seen especially with deeper abscesses;S/S: Snal discharge and pain
65
Anal abscess/fistula (Level 1) Tx
I&D then “WASH”; W arm water cleansing ○ A nalgesics ○ S itz baths ○ H igh fiber diet
66
Anal fissure (Level 2)? s/S?
Painful linear tear in distal anal canal ● Cause: Anal trauma, passage of large/hard stools, low fiber diet ● S/S: Severe rectal pain with bowel movements so patient may avoid BM causing constipation, BRBPR ○ PE: Most common at posterior midline, skin tags may be present if chronic
67
Anal fissure (Level 2) TX?
>80% resolve spontaneously ○ Supportive measures: Warm Sitz baths, pain meds, high fiber diet, stool softeners ○ 2nd line: Topical vasodilators
68
Appendicitis (Level 3) s/s?
S/S: Anorexia, “hamburger sign” (patient does not want to eat), epigastric pain which moves to RLQ, N/V, fever
69
Appendicitis (Level 3) PE:
Rovsing sign: Palpation in LLQ elicits RLQ pain (looks like the word roving so roving pain) ○ Obturator sign: Internal and external hip rotation with flexed knee elicits RLQ pain ○ Psoas sign: Right hip flexion/leg raise against resistance elicits RLQ pain ○ McBurney’s tenderness: Pain at point ⅓ distance from ASIS and navel
70
Appendicitis (Level 3) DX?
CT scan, U/S, ↑WBC
71
Appendicitis (Level 3) TX?
NPO, IV fluids, anaerobic and gram neg antibiotic coverage (simple appendicitis Ertapenem OR Metronidazole + Ceftriaxone), appendectomy
72
Appendicitis (Level 3) Complications?
Perforation or Abscess ○ Perforation: Abx until afebrile with normal WBC and then appendectomy with delayed primary skin closure ○ Abscess: Abx and percutaneous drainage with delayed appendectomy
73
What is Celiac Dz?
Small bowel autoimmune inflammation 2º to gluten causes loss of villi and absorptive area ● Women > Male
74
What is Celiac s/s?
Malabsorption: Diarrhea, abdominal pain, distention, bloating, steatorrhea; And Dermatitis herpetiformis
75
pruritic, papulovesicular rash on extensors, neck, | trunk
Dermatitis herpetiformis
76
Celiac Dz Dx?
+ endomysial IgA Ab, + transglutaminase Ab, small bowel bx
77
Pediatric foreign body ingestion Common ages? Common items?
6MO-3YO Common items: #1 coins, button batteries, pins, toys/toy parts, magnets, marbles, screws
78
Magnets (pediatric foreign body ingestion?
High powered magnets can cause GI perforation ■ Ingestion of 2+ magnets can lead to attraction across bowel layers causing pressure necrosis, fistula, perforation ■ Single magnets may be managed conservatively ● Keep child away from magnetic materials until it passes
79
Button batteries (pediatric foreign body ingestion?
Chemical content, diameter and height of battery is imprinted code on battery ● Eg CR2032 (Content: Lithium/manganese dioxide Diameter in mm: 20mm; Height in tenths of mm: 3.2 mm) ■ Damage depends on how long since ingestion, size of battery, amount of charge left ■ Esophageal injury d/t pressure necrosis ■ Stomach acid can dissolve seal of battery causing chemical release ■ Most serious injuries have diameter >20mm ■ NPO during evaluation ■ Removal necessary of all batteries in esophagus and anywhere if patient has symptoms
80
3rd most common cause of cancer death worldwide,
Stomach Cancer: 15th in US
81
Stomach Cancer risk factors?
tobacco, alcohol, high nitrite diet, H. pylori; Men:Women 2:1; Most common type = adenocarcinoma
82
MC type of stomach cancer?
adenocarcinoma
83
Stomach cancer Clinical features
Symptoms = advanced disease o Anorexia, indigestion, nausea, vomiting, dysphagia, weight loss, melena, early satiety o Later Sx – effusions (pleural & peritoneal), obstruction, jaundice ● May palpate an enlarged stomach, anterior axillary nodes, supraclavicular nodes (Virchow node), periumbilical nodule (Sister Mary Joseph nodule [umbilical metastasis])
84
Stomach Cancer Workup
CBC (iron de), CMP, CEA (50%) & CA 19-9 (20%) | EGD FOR TISSUE DX-ADENOCARCINOMA (90-95%)
85
Stomach cancer TX:
Surgical resection ± nodal resection o Most surgically resected patients will have a recurrence ● Multiple chemo regimens available (commonly used given typical advanced presentation)
86
Pyloric Stenosis
Hypertrophy of pyloric muscle (usually first 4-6 weeks of life) ● Sx: projectile vomiting ● PE: mobile “olive” mass in epigastrum ● Dx: string sign on barium swallow (ultrasound may be preferred initial study) ● Tx: pylorotomy
87
What is Cholangitis (Level 1)
Infection of biliary tract 2º to obstruction from gallstones, malignancy
88
Culprits Cholangitis (Level 1)
Gram neg enteric bacteria ( E. coli, Klebsiella, Enterobacter )
89
s/s of Cholangitis (Level 1)
Charcot’s triad: Fever/chills, RUQ pain, jaundice | ○ Reynold’s pentad: Charcot’s Triad + shock + AMS(altered mental status)
90
DX Imaging of Cholangitis (Level 1)? Labs?
CHOLANGIOGRAPHY *GOLD STANDARD* via ERCP or PTC (percutaneous transhepatic cholangiography)-Done usually after patient afebrile/stable x 48 hours on Abx; U/S and CT -show dilation of common bile duct; Elevated liver enzymes (ALT/AST/Alk phase/GGT), Bilirubin and WBC.
91
TX of Cholangitis (Level 1)
Ampicillin/sulbactam, piperacillin/tazobactam ○ Common bile duct decompression/stone extraction via ERCP ○ Open surgical decompression
92
What is Cholelithiasis (Level 2)
gallstones, no inflammation
93
RF of Cholelithiasis (Level 2)
The 5 Fs” fat, fair, female, forty, fertile | ○ Also Native Americans, cirrhosis, bile stasis, ↑triglycerides
94
Dx of Cholelithiasis (Level 2)
Dx: Ultrasound *gold standard
95
TX of Cholelithiasis?
surgery if symptomatic,Observation if asymptomatic
96
Complications of Cholelithiasis
Choledocholithiasis, acute cholecystitis, acute cholangitis
97
Choledocholithiasis,
resence of stones in bile ducts; the stones can form in the gallbladder or in the ducts themselves. These stones cause biliary colic, biliary obstruction, gallstone pancreatitis, or cholangitis (bile duct infection and inflammation).
98
Chronic hepatitis (Level 1)
Disease > 6 mo; Leads to end-stage liver disease (ESLD) or hepatocellular carcinoma (HCC)
99
Common causes of Chronic hepatitis (Level 1)
Chronic viral infection, alcohol, autoimmune, WILSON’S DISEASE, HEMOCHROMATOSIS, alpha 1 antitrypsin deficiency; 10% HBV, 80% HCV become chronic (also HDV can become chronic)
100
Chronic hep labs?
Labs AST/ALT elevated but < 500; Autoimmune hepatitis: + Anti smooth muscle Ab ○ Wilson’s disease: Low ceruloplasmin, high urine copper ■ Kayser Fleischer rings: Copper deposits in cornea ○ Hemochromatosis: High ferritin, transferrin saturation >50%
101
Chronic Hep B
↑ risk HCC ● 90% perinatally acquired ● Chronic asymptomatic carrier: +HBsAg, +HBeAb with normal labs, undetectable Copyright Hippo Education 2019 - All Rights Reserved 6 HBV DNA, normal liver bx → can still transmit to others ● Chronic infection: +HBsAg, ↑ AST/ALT, ↑HBV DNA, damage seen on liver bx
102
Chronic Hep C- unique testable facts
Serologic markers of chronic infection: HCV RNA and Anti HCV ● CDC recommends 1-time screening for all adults born between 1945-1965, regardless of risk factors
103
What is Cirrhosis (Level 1)
Irreversible liver fibrosis with nodules caused by chronic liver disease
104
S/S of Cirrhosis (Level 1)
Constitutional: Fatigue, weight loss, anorexia, weakness ○ PE: Ascites, hepatosplenomegaly, gynecomastia, spider angioma, caput medusa, bleeding due to ↓ coagulation factors, jaundice, pruritus ○ Hepatic encephalopathy: Confusion, lethargy ■ Asterixis, ↑ ammonia because liver cannot clear it ○ Esophageal varices ○ Spontaneous bacterial peritonitis
105
DX of Cirrhosis (Level 1)
U/S, liver biopsy, LFTs
106
Tx of Cirrhosis (Level 1)
Hepatic encephalopathy: Lactulose to pull ammonia into gut, causes diarrhea ○ Ascites: Na⁺ restriction, diuretics, paracentesis ○ Pruritus: Cholestyramine to ↓ bile salts in the skin ○ *Definitive management* liver transplant ● Screen for HCC with U/S and alpha-fetoprotein
107
Causes of Cirrhosis (Level 1)
``` #1 alcohol, chronic viral hepatitis, non-alcoholic fatty liver disease, hemochromatosis, autoimmune hepatitis, primary biliary cirrhosis, drug toxicity ```
108
What is Colon cancer (Level 1)? Risks?
#3 in US cancer deaths ● Progression from adenomatous polyp to adenocarcinoma usually 10-20 years ● #1 MET LOCATION IS LIVER Risks: Familial adenomatous polyposis, age > 50yr, Ulcerative colitis > Crohn disease, adenomatous polyps , low fiber diet, smoking, alcohol, AA, family history
109
S/S of Colon cancer (Level 1)
Iron deficiency anemia, rectal bleeding, abd pain, change in bowel habits ○ #1 cause of large bowel obstruction ○ R sided masses tend to bleed causing anemia and + fecal occult blood, diarrhea ○ Left sided masses tend to cause obstruction, present later, change stool diameter, hematochezia
110
DX of Colon cancer (Level 1)
Colonoscopy with biopsy, barium enema showing “apple core lesion” , CBC, CEA
111
TX of Colon cancer (Level 1)
Tx: ○ Stage I-III; localized: surgery ○ Stage III + mets: chemotherapy/5-FU
112
Screenings of Colon cancer (Level 1)
USPSTF recommendations start at age 50yr ■ High sensitivity fecal occult blood testing annually ■ Colonoscopy every 10yr from 50-75yr ■ Flex sig every 5yr with FOBT every 3yr ○ If 1st degree relative with colon cancer, screening starts at 40yr or 10 years before relative’s diagnosis
113
Causes of Constipation (Level 3)
#1 inadequate fiber/fluid, poor bowel habits ○ Systemic: DM, hypothyroidism, Parkinsons, MS, hypokalemia ○ Meds: Opioids, calcium channel blockers, anticholinergics, psychotropics ○ Structural: Tumor, stricture, Hirschsprung disease ○ Slow colonic transit: Psychogenic, eating disorders ○ IBS ○ Pelvic floor dyssynergia
114
Alarm S/S of Constipation (Level 3)
Hematochezia, weight loss, anemia, + FOBT (fecal occult blood test)
115
TX Constipation (Level 3)
Fluids ○ Fiber: Retains water and improves transit ○ Bulk forming laxatives: absorbs water and increases fecal mass, softens stool ■ Most physiologic and effective tx ○ Osmotic laxatives: Pulls water into gut and stool ○ Stimulant laxatives: ↑ peristalsis and alters electrolyte transport in the mucosa
116
When to refer for Constipation (Level 3)
For colonoscopy if alarm symptoms or >50yr ○ For biofeedback therapy if defecatory disorder ○ For anorectal testing if refractory constipation
117
Diverticula:
Herniation of the mucosa into the colonic wall causing outpouching ○ Most common at sigmoid colon due to high intraluminal pressure
118
Diverticulosis:
Non-inflamed diverticula | ○ Usually asymptomatic#1 cause of acute lower GI bleeding
119
Diverticulitis:
Inflamed diverticula ○ S/S: Presents like appendicitis mimic on the left, fever, LLQ pain, N/V, diarrhea/constipation, bloating
120
Dx of Diverticulitis/diverticulosis
CT scan ○ ↑ WBC in acute phase (diverticulitis) ○ + guaiac (diverticulosis)
121
Tx of Diverticulitis/diverticulosis
Diverticulosis: High fiber diet, bleeding typically self limited ○ Diverticulitis: Bowel rest, clear liquid diet, antibiotics (Ciprofloxacin or TMP/SMX, plus Metronidazole)

PANRE (15 decks)

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