Flashcards in MTB 2 CK - Gastroenterology Deck (102):
What's the presentation of GERD ? 5 ( Yeah you keep getting this wrong motherfu*ka )
- Substernal Chest Pain without cardiac disease
- Chronic Cough
- Metallic or Sour Taste
- Wheezing Without Reactive airway disease
What is a uncommon cause of GERD ?
- Calcium is a Secondary Messenger for Gastrin
- Ca increased acid production
Which meds are risk factors GERD ? 5
- Estrogen Replacement
All relax the LES
What's the best initial test ? Most accurate test ? When is endoscopy indicated ? for GERD ?
- Best initial Test / tx = PPI for 4-6 weeks
- Most accurate Tx = 24 hour pH monitoring
- Endoscopy indicated when Sx persists or Alarm Sx :
GI bleeding or Anemia
What are the Alarm Sx for GERD ?
- Needs immediate Endoscopic Eval
GI Bleeding or Anemia
When is 24 hour pH is indicated for GERD ?
- Asthma begins in a adult with GERD
- Sleep Apnea is comorbid
- Med Tx has failed
What's the Tx for Gerd ?
- Lifestyle Change
- Medical Tx - PPI
- Surgical Tx - Nissen Fundoplication when PPI fail
What are the FYI's of GERD ?
- H. Pylori Doesn't cause GERD
- Carafate is always the wrong answer
- Antacids have only 20% short term relief
What are the findings of schatzki ring ?
- Intermittent dysphagia
- Midesophagel narrowing on barium swallowing
What is contraindicated in a pt with Zenker Diverticulum ?
- NG tube
- Risks perforation
45 y.o. presents to the ED severe crushing chest pain. Troponin is normal. Ekg is normal. Fat b*tch just hit the startbucks drive thru for a cold frap. Pain doesn't get worse with exertion. Can't swallow and is drooling . What's the Dx ? what's the best test ? most accurate test ? tx ?
- Esophageal Spasm
- Best test - Barium
- Most Accurate test - Manometry shows abnormal only at time of spasm difficult to time
- Tx - CCB
Odynophagia vs Dysphagia ?
- Odynophagia = usually infectious needs a biopsy
- Dysphagia =
younger pt = motility problem
older pt = cancer / stroke
How can you tell Candidal Esophagitis vs CMV or HSV ?
- Candidal can have normal esophagus without ULCERS
Which medications have Pill Esophagitis Reactions ?
72 y.o. Pt has severe substernal chest pain. Burning in nature. Intermittent for several weeks. Sometimes worse with food. PmHx of Osteoperosis. She is Diaphoretic , Distressed . No Crepitus around the clavicles . Had a Hematemesis before admission . What's the Dx ? most accurate test ?
- Pill Esophagitis
- Most accurate test = Endoscopy
Eosinophilic Esophagitis Seen with what sx ?
- Young Pt with odynophagia
- Furrowed appearing esophagus
- Concentric grooves
HSV , CMV Esophagitis viral culture must be taken at the margin. Otherwise you may get a false negative .
- just FYI
What is the tx for Barrett's esophagus ?
Depends on the Endoscopic Findings
- Non Dysplastic or Barrett Esophagus = PPI repeat endoscopy in 3 yrs
- Low Grade Dysplasia: Give PPIs and repeat EGD in 3-6 ( 6-12 months ? ) months
- High Grade Dysplasia or Carcinoma : Surgery
Mallory Weiss vs Boerhaave's Syndrome ?
*Hematemesis no SUB-Q Air
*no Neck Pain tear's usually Distal LES
*full thickness tear 2/2 to retching
How does Esophageal Perforation present ? 4
-Severe Retrosternal Chest pain after vomiting
-Odynophagia and Hematemesis
-Radiation of pain to left shoulder
What is the most accurate test for Esophageal Perf? tx ?
- most accurate = gastrografin esophogram
shows contrast outside the lumen of the esophagus
- Surgery of Esophagus and Debridement of the Mediastinum
- Esophageal Stents
What are the warning signs for PUD / Gastric Ulcer ?
What is the Dx testing for PUD/Gastric ulcer ?
- Upper Endoscopy with Biopsy to rule out cancer
- Duodenal ulcer don't get cancer
How do you dx H. Pylori ? -
- If Endoscopy and Biopsy are done no test needed for
- If not then :
1. Serology : Very Sensitive but can't tell old vs new infections
2. Breath Test and Stool Antigen: Useful to see if tx worked. Sensitivity of both is affected with PPI and antibiotics.
What's the best test for CURED H. Pylori infection ?
- Urea Breath Test
- STool sample
After PUD is resolved . Pt must be RE-Scoped . why ?
- the only way to exclude cancer 100%
- even if biopsy is normal
What's the greatest risk factor for developing Duodenal Ulcer Disease ?
- H. pylori
What is a important agent that doesn't not cause GERD ?
- H. pylori
When is a 24 hour pH monitoring indicated in pts with GERD sx ? 4
- Asthma begins with GERD Sx
- Hoarseness persists
- Sleep Apnea is comorbid
- Medical Tx has Failed
What's the best initial test for GERD ?
- PPI administration
What are the best tx for Achalasia ?
- Pneumatic Dilation
- Surgical Myotomy
What's the clinical sx for Schatzki ring ? tx
- Intermittent dysphagia
- Mid Esophageal narrowing on barium swallow
- Pneumatic Dilation ( same tx in Achalasia ) 4% risk of Perforation
What are Schatzki ring almost always 97% associated with ?
- Hiatal Hernia
What are the esophageal spasms ?
- Sx - starts when drinking cold water
- Diffuse Esophageal Spasm = 20% more contractions on manometry
- Hypertensive Peristalsis ( Nutcracker) = normal contraction in smooth muscle via manometry
- Tx : CCB or Imipramine
- Barium swallow shows Rosebead or Corkscrew shape for Nutcracker
Odynophagia in a old vs young pt etiology ?
- Old = Stroke or Cancer
- young = infectious
What's the MCC of Infective Esophagitis in a AIDs/HIV pt w/
- Candidiasis 90% of the time
- Start with Oral Fluconazole
- Then IV Amphotericin
- Nystatin Oral = Treats only ORAL Candidiasis not Esophageal Candidiasis
- Candida doesn't need to be present to have pt infected vs CMV or HSV causing infective esophagitis
What are the causes of dysphagia ?
- Esophageal Cancer
- Peptic Rings from acid exposure
- Esophageal Spasm
What are the caused of Esophagitis ?
- CMV , HSV , Candidiasis
- Pill Esophagitis
- Eosinophilic Esophagitis
What's the Tx for Plummer Vinson Syndrome ?
Treat Iron Deficiency first = sometimes resolves sx
What esophageal dx needs manometry ?
What is the only way to truly understand the etiology of epigastric pain from ulcer diseases ?
- Endoscopy w/ possible biopsy
When is Endoscopy Indicated for GERD ? -
- Signs of Obstruction like dysphagia or odynophagia
- Weight loss
- Anemia or Heme Positive Stools
- > 5 years of Sx to exclude Barrett's
What are the Sx of Esophageal Perforation ? what's the Dx Test ?
- Retrosternal Chest Pain
- SUB-Q air especially with Heart Beat = Hamman's Sign
- Radiation of pain to left shoulder
- gastrografin esophogram = shows contrast outside the lumen
what's the common presentation of Gastritis ? DX ?
- Bleeding without Pain
- but Severe Erosive gastritis can have pain
- you can't usually answer the Dx question from H/P alone
Dx = needs a endoscopy to diagnose
Which Dx need endoscopy ?
- PUD - Peptic Ulcer ( duodenal and gastric ulcer disease)
- Gastritis ( No Ulcer )
- Non-Ulcer Dyspepsia
- H.Pylori - not needed but most accurate way to diagnose
Stress ulcer prophylaxis is indicated in which pts?
- Mechanical ventilation
- Head Trauma
PPI is the first line tx in ?
Whats the causes of Gastritis vs PUD ?
- H. Pylori
- Portal HTN
- Stress - burns , trauma , sepsis , uremia
PUD - Gastric Ulcer and Duodenal Ulcer
- MC = H. pylori
- NSADIS = 2nd MC
What common irritants do not cause ulcers ?
they delay healing of ulcers
What is the most accurate test for H. Pylori?
What's the best initial test ? Most accurate test for Zollinger Ellison ?
- Endoscopy has to confirm ulcer first then ....
Best initial Test
- Secretin challenge - pt shows high gastrin = positive
- High Gastrin with high gastric acidity despite PPI use
Most Accurate test
- Somatostatin Receptor Scintigraphy with endoscopic Ultrasound exclude metastatic disease
Gastrinoma is usually seen with what sx ?
- Diarrhea because acidity inhibits lipase
What's the most common cause of UPPER vs Lower GI bleed ?
- Upper GI = Ulcer Disease
- Lower GI = Diverticular Disease
When a confirmed case of Gastrinoma is seen what's the next step ?
- Have to exclude metastatic disease
- CT / MRI usually are done but have poor sensitivity
***- Use Somatostatin Scintigraphy ( Nuclear Octreotide Scan) with Endoscopic Ultrasound
- Do this if MRI and CT are normal
What is the cause of diabetic gastroparesis ?
- autonomic damage
- unable to sense stretch of in the GI tract
What's the most accurate test for diabetic gastroparesis ?
- Nuclear Gastric Emptying Study
What sx are seen diabetic gastroparesis ?
- DMII for a long time
Normal Saline or Ringer lactate > 5% dextrose in water why ?
- D5W doesn't stay in the vascular space to raise blood pa as well as Normal Saline
Which is the only type of GI bleed can a Physical exam determine ?
- Variceal Bleeding
What's the MGMT goal of an GI Bleed ?
- Fluid Resus First
- 80% die of inadequate fluid replacement
56 y.o. Cirrhotic Pt has black stool . No hematemesis . NG tube shows bright red blood. What's the Dx ?
- Variceal rupture
What is the sign for NG tube is fully sensitive ?
- Bile in the Aspirate
What's the indication for capsule endoscopy ?
- Small intestine bleeding that can't be reached by endoscopy
What's the TX for GI bleeding ? 6
1) Fluid Resus
2) Packed RBC if HCT =
What's the Tx for Esophageal Varice and Gastric Varice ? 5
3) TIPS = associated with portosystemic encephalopathy . Connects the hepatic vein and Portal Vein
4) Propranolol - prevent future bleeding
5) Antibiotics - prevent SBP with Ascites
Sclerotherapy for Variceal Bleeding is NEVER RIGHT if BANDING is possible
What's the tx for C. Diff ?
- Only Switch to PO Vancomycin if the Metronidazole didn't work or it's a severe case
What's the main diff in Sx for chronic pancreatitis vs gluten sensitive enteropathy celiac disease ?
- Celiac = has Iron DEFICIENCY - needs a intact bowel to absorb Fe
- doesn't Need Pancreatic Juices
What's the best initial test? What's most accurate diagnostic test why else do we do it ? for Celiac ?
Best initial test = anti- gliadin , anti transglutaminase , anti endomysial
Most Accurate = Small Bowel Biopsy to prove villous architecture abnormal and to EXCLUDE LYMPHOMA
What's the most accurate test? what's the best initial test ? for Chronic Pancreatitis ?
- Most accurate = NG tube Secretin Challenge - Normal response is bicarb release
- Best initial = XR or CT for Calcifications on Pancreas
What's the best initial test ? what's the tx ? for Carcinoid ?
- best initial = Urinary 5 hydroxyindoleacetic acid
- tx = octreotide
What's the tx for IBS ?
Anti-Spasmodic Agents and Rest And Exercise
What's the antibody seen in crohns vs ulcerative colitis ?
- Chrons - Anti-saccharomyces cerevisiae pos, ANCA negative
- Ulcerative colitis - Anti-saccharomyces cerevisiae NEG, ANCA POS
what are the extraintestinal manifestations of crohns vs UC ?
- Chronic = Kidney Stones, Erythema Nodosum , Episcleritis , Aphthous Ulcers
- UC = Pyoderma Gangrenosum , Sclerosing Cholangitis
What' the tx in Crohns vs UC ? acute ? chronic ?
- Crohn's - Anti-TNF-Alpha - Infliximab - Surgery is not Curative - Surgery only done for obstruction
- UC - Cyclosporine , Infliximab , Hemi to Total Hemicolectomy - Surgery is curative
Acute = Steroids
Chronic = 5ASA-mesalamine
WHat's the purpose of Azathioprine and 6 mercaptopurine in IBD pts ?
- Used to wean pts of Steroids - Budesonide Specific for IBD
- Give Calcium and Vitamin D
Specific Differences between Crohn's VS UC ?
-Perianal Disease/Abscess ( comes from Anal crypts, don't mix up with crypt abscess of UC that can happen elsewhere)
-Mass and Obstructions
- Anti-Sacchromyces Cerevisiae Pos but ANCA neg
- Cure by surgery
- None of the above
- ANCA pos but ASCA neg
What's the most accurate test for IBD ?
What's the purpose of Azathioprine and 6 mercaptopurine in IBD treatment ?
- Used to wean pt off of steroids
- Everyone needs Calcium and Vitamin D = prevents kidney stones
What's the tx for fistulae in in Crohn's ?
- Unresponsive ? = Surgery
What's the most accurate test for Diverticulosis ?
What can help to dec complications of diverticulosis ? 4
- Inc Dietary Fiber
Diverticulitis sx ?
- LLQ tenderness ( with palpation )
- Palpable mass sometimes
What's the best initial test for Diverticulitis ?
- CT scan
- Don't Colonoscopy or Barium Swallow = Will Perforate
What are the Causes of Lower GI bleeding ? 6
- AVM / Angiodysplasia = Most Common
- Diverticular Bleed = Right Sided Most Common
- Ischemic Colitis
Where's the most common Diverticular bleed vs Diverticulitis ?
- DiverticulaR bleed = Right Sided Most Common
- Diverticulitis = Left Sided
What's the Tx for Diverticulitis ?
- Cipro = Covers GM-
- Metronidazole = Covers Anaerobes
Beta Lactam / Lactamase combo
When do you operate on a pt with Diverticular Disease ? 3
- No response to med
- Recurrence is frequent
- Perforation , Abscess , Stricture or Obstruction
- Young Pt more often than a old pt
Whats the MGMT of GI bleed ?
- Endoscopy - therapeutic and Dx
- Technetium Bleeding scan
What's the dx of Spontaneous Bacterial Peritonitis ?
- Infection without perforation
- Best initial test : > 250 Neutrophils
- Most Accurate test : Fluid Culture with no Gram Stain Findings
What's the Tx ? What's the special MGMT for Spontaneous Bacterial Peritonitis ?
- Tx = Cefotaxime and Ceftriaxone
- HIGH RATE OF RECURRENCE ***
Must prophylaxis with TMP-SMX or Norfloxacin
When are antibiotics needed on Pancreatitis Case ?
- 30% of Necrosis seen
- Use Impenem or Mereopenem
- only way to confirm is biopsy
What's the Triad for Primary Biliary Cirrhosis ?
- Woman in 40-50's
- Fatigue and Itching
- Normal Bilirubin with increased ALK Phos
P. Sclerosing Cholangitis vs P. Biliary Cirrhosis ?
- PSC -
Women in 40's 50's
Fatigue and Itching
Normal Bilirubin with Inc ALK Phos
High ALK Phos
PSC vs PBC Dx test most accurate ?
- PBC = Biopsy and Anti-Mito-Ab
- PSC = MRCP or ERCP
P. Sclerosing Cholangitis is the only cause of Cirrhosis where you DON'T BIOPSY ***
When is Iron Chelation Therapy indicated for Hemochromatosis ?
- Can't be managed with phlebotomy
- Are Anemic and Hemochromatosis from overtransfusion like thalassemia
What's the tx for Chronic HEP B vs Chronic HEP C
- Hep B - can be monotherapy drug
any vir , dine , or interferon
- Hep C - can never be monotherapy
Genotype 1 - ledipasvir and sofosbuvir both orally
Genotype 2,3 - Sofosbuvir and ribavirin orally
What's the best initial test for Wilson's Disease ?
- Slit Lamp for Kayser Fleischer Rings
- Not ceruloplasmin - not the most accurate test b/c all proteins are down with liver dysfunction and cirrhosis
What are the most likely Sx seen with Wilson's Disease ? 3
- Neurological Sx- Psychosis , tremor , dysarthria , ataxia or seizures
- Coombs Neg Hemolytic Anemia
- Renal Tubular Acidosis or Nephrolithiasis
- Wilson's aka Hepatolenticular Degeneration : gives Psychosis and Delusions not DELIRIUM that you would get with LIVER FAILURE
What's the most accurate test for Hepatolenticular Degeneration ?
- Abnormally increased Copper Excretion in the urine after Penicillamine