GI

Question 1

Which patients will benefit from PPI prophylaxis?

Answer 1

1) Burn Patients
2) Increased ICP
3) ICU (especially intubated)

Question 2

Treatment for Acute pancreatitis?

Answer 2

IV fluids, NPO, & IV pain meds

Question 3

Free Air shows up as pure black outside an organ and is indicative of…..

Answer 3

Perforation

Endoscopy+ Peritonitis= Perforation

Question 4

If you suspect gallstone pancreatitis, what is the 1st step in diagnosis?

Answer 4

Upper quadrant Ultrasound

if (+)–> ERCP to remove stone from common bile duct

Question 5

How to find source of a brisk lower GI bleed?

Answer 5

Angiography of mesenteric vessels (IR intervention)

Question 6

Patient w/ melana.. How to find source of bleed?

Answer 6

Start with EGD (allows for visualization, biopsy & intervention). NG tube is controversial (high false negative rate)

Question 7

Treatment for gastroparesis?

Answer 7

Glycemic control & low volume high frequency meals that are low in fiber (easier to digest)

Question 8

When should colonoscopy be done for someone diagnosed with diverticulitis?

Answer 8

First time diagnosis of diverticulitis should be followed by colonoscopy between 2-6 weeks after diagnosis. Do colo too soon–> worsen perforation. Do it too late and miss colon cancer.

Question 9

Diagnosis for patient w/ hyperpigmented skin + diabetes - together with the cirrhosis?

Answer 9

bronze diabetes + cirrhosis = Hemochromatosis. HFE gene mutation–> no “off” signal for iron absorption in gut. Liver biopsy will show elevated hepatocyte iron.

Question 10

GI bleed workup sequence:

Answer 10

1) First test= EGD
2) Brisk bleed= Angiography
3) Ongoing but NOT brisk bleed= Tagged RBC scan
4) Bleeding has stopped= Colonoscopy
5) Bleeding has stopped but you cannot find the source= pill cam

Question 11

what test must be done before doing a nuclear emptying study?

Answer 11

You need to do EGD to make sure there isn’t a tumor, ulcer, or other lesion at the pylorus (mechanical obstruction)

Question 12

Crohns disease:

Answer 12

Chronic watery diarrhea
Skipped lesions anywhere in Gi tract- transmural inflammation
B12 deficiency

Question 13

C difficile treatment:

Answer 13

Nonsevere: Fidaxamicin PO or Vancomycin PO

Severe: Fidaxamicin PO or Vancomycin PO

Fulminant: Metronidazole IV and Vancomycin PO

Question 14

How to prevent esophageal dysplasia progressing to adenocarcinoma?

Answer 14

With low grade dysplasia we can go after endoscopic destruction (burning, clipping, radio-ablation) of the lesion to prevent progression to adenocarcinoma.

Question 15

Primary biliary cirrhosis illness script:

Answer 15

Primary biliary cirrhosis presents in middle age (40s-50s) and presents as a painless jaundice. It is caused by intrahepatic fibrosis of biliary ducts. It occurs in women. Imaging studies are negative (because it is intrahepatic, no obvious obstruction is seen). So if you see woman + 40s + jaundice + cirrhosis + normal biliary imaging, the diagnosis is made as primary biliary cirrhosis. Primary biliary cirrhosis is most associated with anti-mitochondrial antibodies.

Question 16

which is the BEST test to confirm H. pylori eradication?

Answer 16

Stool antigen

Question 17

Primary sclerosing cholangitis illness script

Answer 17

p-ANCA is associated with primary sclerosing cholangitis. Look for a history of ulcerative colitis and then cirrhosis or an obstructive jaundice with an MRCP that reveals “beads-on-a-string.” This occurs in men.

Question 18

Hereditary Nonpolyposis Colorectal Cancer (Lynch Syndrome)

Answer 18

Multiple generations of cancers that include lady cancers (uterus, ovary, breast) and colon cancer. Screen patient at 20-25 yrs or 10 years prior to the earliest colorectal cancer in the family.

Question 19

What antibiotic should be given to patient with ascites and GI bleed?

Answer 19

In the setting of a GI bleed with ascites, the ascites has an increased risk of SBP and so ceftriaxone is given. This is done after stabilization. The acute hemorrhage and risk of death must be controlled, but somewhere in the first 12 hours prophylactic antibiotics against SBP are needed

Question 20

Boceprevir

Answer 20

Treatment for Hep C-Curing Hep C

Question 21

Gallbladder findings in Acute cholecystitis:

Answer 21

pericholecystic fluid, thickened gallbladder wall, and gallstones.

Question 22

MALToma treatment:

Answer 22

MALTomas are exquisitely sensitive to H. pylori treatment. Treatment of H. pylori can reverse the MALToma and cure the cancer. No resection, radiation, or chemotherapy is required (unless there is spread of the tumor outside of the intestinal tract). H. Pylori not only causes ulcerations but it also causes cancer. Treating the H. pylori cures the ulcers and it cures the cancer.

Question 23

If you suspect irritable bowel syndrome in patient rule out:

Answer 23

In patients in whom you suspect diarrhea-predominant irritable bowel syndrome, seek out a diagnosis of Celiac disease first.

Question 24

Gallbladder findings in choledocolithiasis:

Answer 24

Dilated common bile duct with stones in the gallbladder

Question 25

Alpha-1 Anti-Trypsin Deficiency:

Answer 25

A1-AT Deficiency presents in the 40s-60s with COPD and Cirrhosis. It is caused by the PAS + macrophages in the liver, a product of the protease that cannot be excreted by the liver, and so accumulates. Elastase in the lung goes uncorrected, leading to accelerated COPD. Protease granules in the liver cause inflammation, and lead to cirrhosis.

Question 26

Diagnosing Zollinger- Ellison Syndrome (gastrinoma):

Answer 26

Gastrinomas produce gastrin regardless of feedback from stomach acidity, leading to parietal cell hypertrophy, extremely low pH that breaks down the mucosal barrier, and puts the patient at risk for malignant transformation of the parietal cell (gastrin acts as both a stimulus for acid secretion and as a growth signal). The first step is an endoscopy to confirm ulceration. The next step is to obtain a serum gastrin level. A gastrin level > 1000 needs no confirmation. A gastrin level in the triple digits is confirmed with a secretin stimulation test which will reveal a paradoxical increase in gastrin levels on administration of secretin. The somatostatin receptor scintography and CT scan of the abdomen are used to identify the location of the tumor, often located in the pancreas. These tests would be done after the secretin stimulation test in order to stage the disease.

Question 27

Gallbladder findings in malignancy:

Answer 27

Thin-walled, distended gallbladder

Question 28

Management options for esophageal varices-TIPS procedure

Answer 28

The TIPS procedure bypasses the liver and just takes unfiltered blood from the portal system and dumps it back into the vena cava. This relieves the pressure but puts the patient at serious risk of hepatic encephalopathy. TIPS is performed when varices are refractory. Bridge to transplant

Question 29

Management options for esophageal varices: Octreotide

Answer 29

In the setting of a GI bleed every patient should get two large bore IVs, typed and cross, a GI consult for endoscopy, and a proton pump inhibitor infusion. If he/she is a cirrhotic, he/she should get octreotide as well. This reduces the portal pressures and the assumption is that the bleeding will slow.

Question 30

Management options for esophageal varices: endoscopic variceal banding

Answer 30

When portal hypertension causes increased pressure and volume within the superficial veins along the esophagus, they rupture. And unlike arteries, they don’t have muscles lining their walls to enable constriction and slow the bleeding. So, bleeding esophageal varices are the one cause of UGIB that will kill your patient in mere hours–> RUBBER BAND THEM

Question 31

Management options for esophageal varices: Ceftriaxone

Answer 31

When you have ascites and there is a GI bleed there must also be prophylaxis against spontaneous bacterial peritonitis. That is done with IV ceftriaxone.

Question 32

Gallbladder findings in cholelithiasis:

Answer 32

Gallstones in the gallbladder

Question 33

Hepatocellular carcinoma screening:

Answer 33

Hepatocellular carcinoma (HCC) screening is with Ultrasound and AFP, performed every 6 months, for patients with cirrhosis only. Otherwise no screening is needed.

Question 34

Hepatocellular carcinoma screening in Hep B patients:

Answer 34

The screening guidelines for Hep B are much more aggressive than Hep C. Hep B is more oncogenic than Hep C and you can get HCC without cirrhosis from Hep B. So, start early (Asian males > 40, Asian woman > 50, or evidence of cirrhosis

Question 35

Painless bright red blood per rectum. This is a fast bleed.

Answer 35

most likely cause of a brisk lower GI bleed is diverticular hemorrhage and thus diverticulosis. The bleeding from hemorrhoids is often not sufficient to produce hematochezia and acute blood loss.

Question 36

Ulcerative colitis treatment:

Answer 36

Ulcerative colitis presents with bloody diarrhea and tenesmus (recurrent inclination to evacuate the bowels).

Mild disease can be treated with 5-asa compounds alone.

Moderate disease and in flares: Prednisone

Cyclosporine is a toxic medication used when prednisone fails to control a flare.

Once there is severe disease, disease refractory to therapy, or it has been 8 years a colectomy can be performed.

Question 37

Screening guidelines for colon cancer in the setting of ulcerative colitis

Answer 37

Without prophylactic colectomy screening guidelines for colon cancer in the setting of ulcerative colitis are to start at 8 years from diagnosis and then get annual colonoscopies. Resection is curative of UC and prevent malignant transformation and is preferred.

Question 38

Celiac Sprue patient presentation:

Answer 38

Celiac Sprue can present as iron deficiency anemia, osteoporosis, or folate deficiency.

Question 39

Barrett’s Esophagus

Answer 39

Barrett’s Esophagus is a metaplasia with shift from the stratified squamous epithelium of the distal esophagus to columnar epithelium. It can be identified on endoscopy.

Question 40

Crohn’s disease treatment:

Answer 40

Fistulizing Crohn’s disease is severe and is treated with anti-TNF-alpha inhibitors like Infliximab for induction and maintenance.

Mild: mesalamine
flares: mesalamine and steroids

Question 41

Obstructive jaundice

Answer 41

Obstructive jaundice is either stricture or cancer; when the diagnosis is likely to be primary sclerosing cholangitis (PSC), obtain MRCP as the first test which will show beads-on-a-string

Question 42

When is CT scan used in pancreatitis?

Answer 42

Lipase elevations are sufficient to diagnose pancreatitis; CT scans are necessary only when there is clinical suspicion that is lacking enzymatic evidence.

Question 43

Antibiotics in pancreatitis :

Answer 43

No matter how severe the pancreatitis or how necrotizing the pancreatitis, do NOT give antibiotics until you’ve taken a piece of the pancreas. That means you treat literally every pancreatitis the same way: fluids, analgesia, bowel rest. If they start to get worse, spike fevers, etc. THEN you go and grab a piece with a biopsy and start antibiotics.

Question 44

diagnosis of caustic ingestion

Answer 44

An assessment for severity must be made early to determine how long the patient must be observed. If there is only mild erythema and mild ulcers, feedings can be initiated early. If severe, the patient may need to delay using his esophagus to prevent complications. Endoscopy is required to assess for severity.

Question 45

Severe C. diff treatment:

Answer 45

Treat severe C. diff with a combination of IV Metronidazole and oral vancomycin

Question 46

Biliary Cholestasis

Answer 46

characterized by an isolated elevation in the Direct Bilirubin and Alkaline Phosphatase in the setting of sepsis (or other inflammatory condition). absence of gallstones on ultrasounds rules them out, leaving you with cholestasis.

Question 47

Ulcerative Colitis (UC)

Answer 47

Only involves Colon

Crypt abscesses

Pseudopolyps

(+) Antineutrophil cytoplasmic autoantibodies (ANCA)

Question 48

Crohn’s disease

Answer 48

Can involve any part of GI tract (skip lesions)

Transmural noncaseating granulomas

Fistulas and abscesses masses and obstruction, and perianal disease

Question 49

Sigmoid volvulus

Answer 49

• Progressive or acute abdominal pain associated with nausea and vomiting
• Diagnosis made with plain film, which will show a double loop or coffee bean sign

Question 50

Anorectal fistula

Answer 50

Epithelized tract that connects the anus or rectum to the perirectal skin

Pain and purulent drainage in the absence of a fever are associated with an anorectal fistula

If fever it’s probably perianal abscess

Question 51

Autoimmune hepatitis

Answer 51

Unknown etiology

Serum aminotransferase levels 200-300U/L range

Dx: Anti-smooth muscle antibodies

Question 52

Budd-Chiari syndrome treatment

Answer 52

Form of liver disease caused by the obstruction of hepatic venous outflow by thrombosis.

Acute-onset abdominal pain, ascites, and hepatomegaly

Tx: Unfractionated heparin infusion

Question 53

Diarrhea and metabolic dysfunction

Answer 53

Non-anion gap Metabolic acidosis

Question 54

Vomiting/ Emesis

Answer 54

Metabolic alkalosis

Usually with alveolar hypoventilation