GIT

Question 1

Started from GIT Q 15 of test 2 of 4, 9961

Choledocholithiasis Dx and Rx

Answer 1

1. ERCP, later can do elective lap chole
   CT - for AP
   HIDA- if US not Dx GSD
   imme lap chole if - GB perf, shock. END

Question 2

Ps cyst panc

Answer 2

2. -It is aseptic, after >4 wks of AP
   - Necrotizing pancreatitis l/t fever, leucocytosis, collection of septic fluid (<4 wks)
   - Supportive Rx, if severe s/s then UGIE drainage, Sx
   - Splenic V thrombosis-asso w/gastric varices, portal HT, ascites, congestive splenomegaly. END

Question 3

• UGI bleed-ulcer (black tarry stools mostly, 15% cases w/rapid large UGI bldg - bright red maroon stools)
• LGI bleed (diverticulosis, piles)

Answer 3

-do EGD w/hemostatic clipping

• do colonoscopy
  none of above successful do CT angio, angio embolization, video capsule endoscopy, radionucleide bldg scanning

Question 4

Rectal prolapse

Answer 4

chr constipa, BPH, piles(int piles), multiparity, pelvic Sx / pelvic floor dysfunc, stroke/dementia
s/s-consti, BPR, fecal inconti
Rx-med if asymp/minor s/s-pelvic floor xcise, fiber th
Sx if sev s/s of gangrene( rectosig ectomy)

Question 5

-Enteral feeds by gastrostomy done Sx, UGIE, interven radio

Answer 5

• 30 Kcal/Kg/d and 1g/Kg of pro
• lower cal given in malnurition to avoid refeeding synd
• Ix of gastrostomy-oral ulcers, dysphagia, pharyngeal Ca, stroke, PD

Question 6

Rx of UGI bldg

Answer 6

• IV fluids
• IV PPI
• UGIE
• BT like PRBC needed only if Hb<7, major Sx, ACS, severe TCP, Ca w/bldg risk, hemo instability, massive bleeds, anemia s/s like CP, syncopy not fatigue
• Plt given if plt<50,000
• octreotide for varices
• alb infusion if spont. bact. peritonitis or paracentesis

Question 7

5347

Ix Colonoscopy

Answer 7

• done after 50y avg pt
• Flexible sigmoidoscopy has less bowel prep than colono but not able to visualise prox colon
• if flex sig result shows large tub villous adenomas, large multiple adenomatous polyps then need colono imme
• if flex sig normal do it q 5y or q10y w/annual FOBT

Question 8

5666

Duo ulcer

Answer 8

• d/t h pylori
• Rx clarithro, amoxi, Omz
• pain on empty sto, relieved w/meals, less malig
• confirm H pylori w/serology
• after 4 wk eradication tested w/ urea breath/stool Ag
• Gastric ulcer-more malig, pain after meals, not d/t H pylori

Question 9

5980

Perianal /ischiorectal abscess

Answer 9

• Rx I n D, antibiotics

- intense pain, fever, malaise

Question 10

5981

Perianal abscess

Answer 10

More likely to have fistulas

Question 11

6102

Small bowel obs

Answer 11

• multiple air fluid levels on XR
• N/V, abd pain
• abd tense
• increased bowel sounds
• tympanic note throughout the abd
• tender lower abd
• Rx supportive n conser for 12-24 hr, if not improve-Sx
• mesen ische/hernia stangulated need emg Sx

Question 12

6351

Hep hydroTx

Answer 12

• Coz- rt hemidiaphragm porous/thin so ascitic fl in ALD penetrates pl cavity-pl effu, d/t cirrhosis
• light criteria-exudate if pl fl pro/s. pro>0.5, pl fl LDH/S LDH >0.6, pl fl LDH >2/3 of S LDH
• Rx is spirono, furosemide , Na restriction
• Trasudate-CHF, nephrotic, cirrhosis, constrictive pericarditis
• exudate-inflammation, transudate-H static/oncotic P
• talc- put in recurrent malig pl effu bet 2 layers to fuse them
• TIPS- fistula bet hep V n portal V to dec Portal Venous P

Question 13

6066

GERD

Answer 13

-reduced LES sphinc tone, LES relaxation, hiatal hernia
-alc, obese, preg, smoking cozes this
-start w/diet, PPI/H2 # for 8 wk
-if not do eso pH monitoring
-Cx erosive esophagitis, Barretts, strictures
asthma, laryngitis
-cuf, hoarseness, wheeze, ht burn, reflux, dysphagia

Question 14

13451

Func abd pain in children n adolescents

Answer 14

• normal abd exam
• periumb/poorly localized abd pain, no triggers
• no N/V, diarr, bowel pattern changes, bloating, flatus
• FOBT neg
• chr >=2 mo
• rassure, symp diary

Question 15

5368

Fecal impaction w/fecal inconti

Answer 15

• Rx disimpaction, enema, suppository, oral regimen to prevent recurrence
• cozes-elder w/constipation, slow fecal transit, dec anal sensation, dec fiber, dec sphinc tone in elderly
• Dx by PR
• anal fissure intense pain cozes consti–Rx sphincterotomy

Question 16

5635

ingestion of sharp objects like pins, needles, fishbones, ,toothpicks, chicken bones

Answer 16

• do UGIE urgent, as can coz eso perforation

- not allowed to stay for >24 hr

Question 17

6025
Chr diarr (loose stools for >=4 wks)

Answer 17

• D/Ds-celiac, lactose intole, IBD, IBS, chr infection

- stool exam done for ova, parasites, leuco, pH, osm gap, electrolytes, occult blood, staining for fat

Question 18

6026

1. dec osm gap <50, secre diarr Dx is
2. inc osm gap >125
3. villus atrophy w/lympho infil
4. subepith collagenous band
5. transmural infla w/lymho infil
6. normal Bx
7. Giardia

Answer 18

1. Collagenous colitis
2. CD celiac ds and LI
3. CD
4. collagenous colitis
5. IBD
6. IBS
7. villus flattening
   - CD Bx taken from distal duodenum
   -Bact overgrowth synd-lactulose breath test +, vit B12 def ane
   -LI- lactose breath test +, dec stool pH
   -CD -microcytic ane, anti Ts transglutaminase
   -290 mOsm/kg − 2 x (stool Na + stool K)
   <50-Secre diarr
   50-125-Indeterminate
   >125-Osm diarr

Question 19

6027

CD Rx

Answer 19

• gluten free wheat, rye, barley
• can eat rice, potato, soy, corn
• D. herpetiformis- dapsone
• osteoporosis-DEXA scan
• supple w/Vit ADEB 12, B 1, Fe, FA, Ca
• pneumococcal vaccination
• extra-bile acid binding resins Rx of IBS
• IBD Rx-5 amino salicylates
• whipple ds (arthralgias, diarr, wt loss) - Rx antibio

Question 20

5014

• -colon Ca screening
• 1. Avg risk –General population & single first-degree relative age >60 with colon cancer or adenomatous polyps

-2. Inc risk—First-degree relative age <60 with colon cancer or adenomatous polyps &
>2 first-degree relatives with colon cancer or adenomatous polyps at any age

Answer 20

-1. Start screening at age 50. Options include:

Colonoscopy every 10 years
gFOBT or FIT every year
FIT-DNA every 1-3 years
CT colonography every 5 years
Flexible sigmoidoscopy every 5 years (or every 10 years combined with annual FIT)

-2. Colonoscopy at age 40 or 10 years before the age of cancer diagnosis in a relative (whichever comes first)
Repeat every 3-5 years

Question 21

5272

M Diverticulum

Answer 21

-2% prevalence
-2:1 male-female
-2 y of age
-within 2 ft of ileocecal valve
-tech 99 scan-conc in gastric parietal cels of MD, sto
-Rx of symp MD is Sx resection
-s/s-painless bldg, anemia in young child, adults n adolescent-obstruction
-D/Ds- MD, vas malform
-failure of vitelline duct to obliterate during the first 8 wks of gestation
Cx-intussussecption, volvulus, IO

Question 22

12797

Viral GE, norovirus, rotavirus,

Answer 22

• ORS
• hyposmolar ORS w/glu good if not much dehydration else IV
• no fruit juice apple has fructose, sorbitol so inc the osm load in SI n coz fructose malabs
• lactase def occurs d/t inflmmation of intes epith
• water alone bad as hypogly, hypoNa
• CF-steatorrhea, fail to thrive, infec

Question 23

5007

AD colon cancer syndromes (eg, hereditary nonpolyposis colon cancer, familial adenomatous polyposis

Answer 23

• inc risk of colon Ca
• aspirin given to prevent colon Ca if 10 yr risk of CV events is >10%
• rt sided colon Ca may be asymp

Question 24

5790

Celiac ds untreated

Answer 24

• hemato malig in proximal jejunum
• enteropathy asso T cell lymphoma
• diarr, bloody stools, abd pain, conssti s/s, bowel obs, perf
• poor prog
• CMV colitis -AIDS, fever, bloody stools, diarr, abd pain
• Bact overgrowth- flatulence, bloating
• gastrinoma-rare neuroendocrine tu, diarr, wt loss, bloody stools, abd pain, PUD
• Chron ds-abd pain, bleeding stools, diarr, wt loss

Question 25

5886 | Hematochezia elderly

Answer 25

- D/D diverticulosis, piles - hemo stable do colonoscopy, not help do EGD, still not do capsule endoscopy, repeat colono, EGD - hemo unstable - do EGD to see UGIB, not help then angio then if hemo stable do colonoscopy - Liga of treitz sepa UGI/LGI - hemetemesis, malena, orthostasis, BUN:creat >20:1-UGIB - gastric lavage no bld only bile - LGIB - NCCT -retroperitoneal bleed, perito cavity bleed - diverticulitis-colonoscopy CI as can coz perforation - if colono, angio not help do RBC tagged scan, Sx

Question 26

5216 | FB ingestion pediatric

Answer 26

- 6 mo-3 y - do serial PA lateral XR - if symp of obs, resp distress-sharp object, magnetic, then imme endosco removal - asymp- do serial XR wkly, transit occuring-no intrevention - if no transit-endoscopy removal - coins MC , not sharp, non toxic - in eso, lodged in narrow part of LES - emetic ipecac CI as l/t proximal lodging - Ba study CI as obscure GIT view if later endoscopy needed - CT scan if symp, object sharp, unwitnessed ingestion

Question 27

5185 Test 20, GIT, 3 of 4, Angiodysplasia

Answer 27

- cherry red spots on colono - incidental - FOBT + - submucosal venous occlusion, congestion n ectasias, vas malform - asso w/AS, vWD, ESRD all coz bldg diathesis, plt dysfxn - Dermatomyositis-infla myopathy, heliotrope rash, gottron pustules, asso w/ lung, ova, colon Ca - pri scle cholangitis-scarred bili ducts, l/t cirrhosis, asso w/ UC - anky spondylitis asso w/ UC/CD - CD-cobblestone w/skpi lesions, abd pain, diarr, wt loss - UC-bldy stool, tenesmus, abd pain, diarr, wt loss, friable inflamed mucosa - TR asso w/carcinoid-flushing, diarr

Question 28

13333 | Ac dysentry

Answer 28

-diarr <14 d -salmo, shige, EHEC, campy, amebiasis -non infec-ische colitis, IBD -stool C/S, leuco, shiga toxin -EHEC no antibio as antibio coz HUS -CT -ische colitis Endoscopy -IBD -C diff colitis-non bloody diarr

Question 29

5658 | Splenic V thrombosis

Answer 29

- d/t panc infla, AP, CP, panc Ca as splenic V runs on back of panc - isolated gastric varices - fundal varices - Rx spleectomy - s/s-ascites, hypersple-TCP, anemia, blood in vomitus, lt sided PHT, splemeg - Budd chiari- hep V. or supra/intra hepatic IVC thrombosis - hep veno occlusive ds- thrombosis of hep venules, tender hepmeg, in BMT pt - constric peri-RHF s/s - PHT - in cirrhosis

Question 30

Fe def anemia

Answer 30

- MCV low - colon ca- FOBT +, fe def anemia - EPO prod by kidneys, dec in ESRD, CKD

Question 31

Ac dysentery

Answer 31

- salmonella, shigella(shiga toxin rest bact do direct enterocyte invasion), campylo, EIEC, EHEC, yersinia - antibio in Ecoli O157:H7 can coz HUS - bloody stools dx bld c/s - Viral n parasitic diarr- non bloody-Dx by ova n parasite, h/o travel, contami water - Rx ORS if no s/o dehydration - Juice w/sorbitol so not given can aggravate diarr - give water w/glu n electrolytes-to prevent hypoNa, hypogly - Intussusception-bloody stool, abd pain, no fever, age <2 y, Dx US

Question 32

Physician advice on wt loss diet, xcise

Answer 32

- non judgemental, empathetic, pt centered approach | - implement a structured program

Question 33

Ac mesen ische

Answer 33

- AF, cardiac emb coz SMA obs - SMV obs by hypercoag ds, PHT, abd inf - severe peri umb pain - leucocytosis - MAci - Hemoconc - CT angio - Rx fluids, electro, NG, Sx - Ac colonic ische, partial ische, splenic flexure, rectosig, less pain compared to SMA ische - CT abd -s/o small bowel ische (focal or segmental bowel wall thickening, intes pneumatosis w/ portal vein gas, dila bowel, mesen stranding - diverticulitis- LLQ pain - IO-air fluid levels, dila bowel, constipation, diatended abd, hyper BS - AIPorphyria-abd pain, neuropathy, tachy, hypoNa