Ditt Step 2 Day 8 Gi

Front 1

What is the tx for acute mesenteric ischemia?

Back 1

- Hemodynamic monitoring
- Pressors
- Broad spectrum antibiotics
- NG tube decompression
- Heparin or Enoxaparin
- Papaverine
- Resection of Necrotic Bowel

Front 2

When is Rifampin prophlaxis indicated in cases of bacterial meningitis?

Back 2

pg 169
close contacts or pt is diagnosed with neisseria meningitidis or H. influenza type B

Front 3

What is the treatment for acromegaly?

Back 3

(1) transphenoidal resection of pituitary adenoma
(2) beam radiation
(3) somatostatin
(4) cabergoline

Front 4

What are the most common causes of acute pancreatitis?

Back 4

gallstones & alcohol

Front 5

A COPD pt comes to the ER with tachycardia & hypotension. During the evaluation he begins to have seizures. What is the most likely etiology?

Back 5

Theophylline overdose

Front 6

What is teh ACLS tx for asystole?

Back 6

pg 155
transcutaneous pacing
CPR
epinephrine

Front 7

What is the treatment for febrile seizures?

Back 7

pg 189

↓ temperature
reassurance (DONT need anti-epileptics)

Front 8

What is the empiric treatment for pneumonia in a 2 month old? in a 2 yr old?

Back 8

2 mo old = macrolide +/- cefotaxime

2 yr old = amoxicillin or ampicillin

Front 9

What are the causes of osmotic diarrhea?

Back 9

Malabsorptive disorders (Pancreatic insufficiency, Celiac Sprue, Whipple Disease, Tropical Sprue)
- Lactose Intolerance
- Excess sorbitol (chewing 3pks gum/day)
- Lactulose
- Magnesium

Front 10

What are the causes of Secretory Diarrhea?

Back 10

Hormone-related tumors (VIPomas, Gastrinomas, Medullary Thyroid Cancer, Carcinoid Tumors)
- Enterotoxigenic bacterial infections
- Ileal resection

Front 11

Where in the GI tract is alcohol absorbed?

Back 11

stomach

Front 12

Where in the GI tract is Vit B12 absorbed?

Back 12

terminal ileum

Front 13

Where in the GI tract are bile salts reabsorbed?

Back 13

terminal ileum

Front 14

Where in the GI tract is potassium absorbed?

Back 14

colon

Front 15

What 2 serum markers aid in the diagnosis of Celiac sprue?

Back 15

pg 67

anti-endomysial antibodies
anti-gliadin antibodies

Front 16

What does the intestinal biopsy show in a pt with celiac sprue?

Back 16

blunting of villi in duodenum & jejunum

Front 17

What hematological finding commonly coincides with tropical sprue, and how do we treat this?

Back 17

Megaloblastic anemia

tx: Folic acid supplementation

Front 18

What differentiates an intestinal biopsy of celiac sprue from one of Whipple disease?

Back 18

celiac sprue = blunting of villi

Whipple disease = foamy macrophages (PAS stain)

Front 19

A pt is undergoing testing to identify the cause of her anemia. She was unable to absorb oral Vit B12, but when she was given B12 along with intrinsic factor, she was able to absorb the B12. What is her diagnosis?

Back 19

(note that this was describing the Schilling test)
Dx: Pernicious Anemia

Front 20

What labs should be ordered to identify the pathogen in a pt with an acute diarrheal illness?

Back 20

(assuming no fever or bloody diarrhea, -- which probably viral and don't need to do anything)
If there is a fever or bloody diarrhea for more than 5 days:
- stool culture (for bacteria), stool acid fast stain, check stool for fecal leukocytes
- stool ova & parasites, stool guaiac

Front 21

What is the most common cause of adult chronic diarrhea?

Back 21

Lactose intolerance

Front 22

What are the ROME II Diagnostic Guidelines for Irritable Bowel Syndrome (IBS)?

Back 22

(1) At least 12wks of abd discomfort or pain in the preceding year assoc with one of the following:
- relief with defecation
- change in FREQ of stool
- change in FORM of stool

(2) characteristic of IBS: change in stool form or freq (>3 daily or <3 weekly), straining, ugency, or feeling of incomplete passage, bloating/ distention, mucus

(3) NOT characteristic of IBS: anorexia, weight loss, malnutrition, progressively worsening pain, pain that prevents sleep

Front 23

What is the necessary workup before making the diagnosis of diarrhea predominant form of IBS? Tx?

Back 23

- Labs: serum tissue transglutaminase antibody to r/o celiac sprue, CBC, Chem 7, TSH (hyperthyroidism can cause diarrhea), ESR, stool leukocytes
Treatment:
- Tricyclic antidepressants (desipramine) or SSRIs (if TCAs not well tolerated)
- if woman has severe disease -- alosetron (Lotronex)
- Loperamide (Imodium) PRN

Front 24

What is the tx for the constipation predominant form of IBS?

Back 24

Fiber bulking agents

Front 25

What treatments are available for managing Crohn's Disease?

Back 25

(1) 5-ASA agents (ie mesalamine, sulfasalazine) - usual initial therapy for mild disease
(2) Azathioprine or mercaptopurine > methotrexate
(3) Anti-TNF-α agents (Infliximab, adalimumab)
(4) Steroids +/- antibiotics for acute exacerbations

Front 26

What are the most common causes of small bowel obstruction (SBO)?

Back 26

mneumonic: "ABC"
(1) Adhesions from previous surgeries (~75% of cases)
(2) Bulge (hernia)
(3) Cancer (most commonly metastatic colorectal cancer)
(4) Other less common causes: volvulus, intussusception, Crohn's Disease, Gallstone Ileus, Bezoar (organic matter that balls up), bowel wall hematoma from trauma, inflammatory stricture, congenital malformation, radiation enteritis

Front 27

What are the classic s/s of SBO? What radiographic findings help you confirm the diagnosis?

Back 27

S/S: abd pain/ tenderness, N/V, +/- recent flatus/small BM; high-pitched hyperactive BS (also common is h/o prev abd surgery - think adhesions)

Dx: Distended loops of small bowel prox to the obstruction seen on plain film abd series or CT scan of the abdomen

Front 28

What is the tx for a SBO?

Back 28

- NPO, IVF (usually LR) monitor electrolytes, Foley cath to monitor UOP
- NG tube to low intermittent wall suction (LIWS)
- Hospital observation with freq reassessments +/- repeat CT scans
- Avoid pain medication if possible which may interfere with identification of disease worsening
- Surgery (laparotomy & lysis of adhesions) if:
... no improvement in 12-24hrs
... complete SBO
... suspected, impending, or ongoing strangulation

Front 29

What are the seronegative arthropathies?

Back 29

"PAIR" - assoc with HLA-B27
Psoriatic arthritis
Ankylosing Spondylitis
Inflammatory Bowel Disease
Reiter's Syndrome

Front 30

According to the ROME II Diagnostic Guidelines for IBS, what s/s are NOT characteristic of IBS?

Back 30

Anorexia, weight loss, malnutrition, progressively worsening pain, pain that prevents sleep

Front 31

Which form of IBD is often positive for ASCA and negative for pANCA?

Back 31

ASCA = anti-yeast saccharomyces cerevisiae antibodies
pANCA = perinuclear antineutrophilic cytoplasmic Abs

= Crohn's Disease

Front 32

Which form of IBD causes perianal fissuring & fistulas?

Back 32

Crohn's Disease

Front 33

In which form of IBD would you see a "lead pipe" appearance on barium enema?

Back 33

Ulcerative Colitis

Front 34

What are the first-line treatments for IBD?

Back 34

5-ASA medications (Mesalamine, Sulfasalazine)

Front 35

What are the 3 most common causes of SBO in descending order (in the US)?

Back 35

"ABC"
Adhesions
Bulge (hernia)
Cancer

Front 36

What is the most common cause of large bowel obstruction?

Back 36

cancer

Front 37

What is the most common BENIGN small bowel tumor?

Back 37

leiomyoma

Front 38

what is the most common MALIGNANT small bowel tumor?

Back 38

adenocarcinoma

Front 39

What radiological studies can be used to diagnose appendicitis?

Back 39

- CT scan with oral contrast (2 hrs required, but allows visualization of pathology in the entire abdomen)
- CT scan with rectal contrast (+/- IV contrast) - fastest & most accurate CT scan
- CT scan without contrast - higher rate of false negatives, still better than no CT scan
- Plain xray - may aid in the diagnosis but does not allow you to make the dx
- Ultrasound - good first study in children, not as accurate as CT scan, can identify any pelvic pathology present in women

Front 40

What is the specific treatment for appendicitis?

Back 40

- NPO & IVF
- Pain control: morphine or meperidine PCA
- Antibiotics ASAP (Unasyn, ZOsyn, Levofloxacin+metro, Cipro + metro, Ampicillin + levofloxacin + Metro, Imipenem/cilastatin, Meropenem
- Surgical removal
- if abscess seen on CT scan do percutaneous drainage via IR

Front 41

What is the classic presentation of gallstone ileus?

Back 41

- gallstone ileus is impaction of a gallstone in the ileum after passage thru a biliary-enteric fistula
classically presents as an episodic subacute obstruction in an elderly female = vague, recurrent abdominal pain & vomiting that recurs as the stone repeatedly lodges & dislodges
- avg time from symptom onset to hospitalization = 5 days

Front 42

What is the treatment for sigmoid volvulus?

Back 42

(1) sigmoidoscopy or colonoscopy for decompression
- volvulus usually 25cm from the anal verge
- contraindicated if signs of gangrene due to perforation risk
(2) if gangrenous or scope unsuccessful = lap resection of the affected colon and colostomy
(3) once corrected, the recurrence rate in 40-60% of pts can be prevented with one of the following:
- mesosigmoidopexy
- resection with primary anastomosis
- Hartman's procedure (proximal colostomy + stapling but not removal of the distal segment)

Front 43

What might you see on CT scan of the abdomen in a pt suspected of having ischemic colitis?

Back 43

(1) Bowel wall thickening
(2) air w/in bowel wall (pneumatosis coli)

Front 44

What is the classic presenting history of appendicitis?

Back 44

- dull periumbilical pain, N/V, anorexia
- pain migrates to RLQ & becomes more severe

Front 45

In a woman with history and labs suggestive of acute appendicitis, what additional lab should be done first before surgery?

Back 45

Pregnancy test (check B-hCG)

Front 46

Describe the different signs that might be seen in pts with appendicitis

Back 46

(1) Psoas sign = RLQ pain on passive extension of hip
(2) Rovsing's sign = RLQ pain with LLQ palpation
(3) Obturator sign = pain on passive internal rotation of flexed hip

Front 47

HYQ: What is the classic time-frame for which post-op ileus resolves in the different parts of the gut?

Back 47

pg 72
small bowel = <24hrs
stomach = 48-72hrs
Colon = 3-5 days

Front 48

What patient populations are most susceptible to volvulus

Back 48

- infants & elderly

Front 49

What should you look for on an abdominal xray in a pt suspected of volvulus?

Back 49

- bowel distended with air proximal to volvulus
- volvulus itself distended with air ("double bubble")

Front 50

HYQ: What is the next step in the management of a pt that comes to the ER with severe abdominal pain and abd xray shows free air in the abdomen?

Back 50

think perforation (b/c of free air)
tx: exploratory laparotomy

Front 51

HYQ: A recent Cuban immigrant with symptoms of malabsorption is found to also have megaloblastic anemia. What is the disease and treatment?

Back 51

Dx: Tropical Sprue
Tx: Folate + tetracycline or sulfa drug

Front 52

Elderly pt presents to the ER with vomiting, abd pain + distention. Abd Xray reveals two distinct but sequential portions of bowel in the sigmoid colon that are distended with air. What is the treatment?

Back 52

Dx: Volvulus ("double bubble")
Tx: Colonscopy (try to untwist portion of affected colon)

Front 53

What is the treatment for Crohn's Disease

Back 53

5-ASA
Azathioprine or mercaptopurine
Anti-TNFa agents
Steroids
Antibiotics

Front 54

What is the classic characteristic of acute mesenteric ischemia?

Back 54

Pain out of proportion to physical exam findings

Front 55

Which characteristics are associated with IBS?

Back 55

Bloating, mucus
abd pain relieved with defecation
change in freq/form of stool
straining, urgency, feeling of incomplete passage

Front 56

Which characteristics are NOT assoc with IBS?

Back 56

anorexia, weight loss, malnutrition, progressively worse pain, or pain that interferes with sleep

Front 57

What tumors can cause a secretory diarrhea?

Back 57

Carinoid tumor
VIPoma
Gastrinoma
Medullary Thyroid Cancer

Front 58

What is the most likely cause of malabsorption in a pt with (+) Sudan stain in the stool sample and a normal D-xylose test?

Back 58

Pancreatic insufficiency

Front 59

What is the treatment for Whipple disease?

Back 59

TMP-SMX (Bactrim) or Ceftriaxome for 12 months

Front 60

What serum lab findings might help you distinguish Crohn's from UC?

Back 60

Crohn's = (+) ASCA
Ulcerative Colitis = (+) pANCA

Front 61

When is inpatient admission for diverticulitis treatment indicated? What are the steps in the inpatient management of diverticulitis?

Back 61

● the following pts need to be hospitalized for tx of acute diverticulitis: elderly, immunocompromised, significant comorbidities, high fever, and significant leukocytosis, unable to tolerate PO intake... otherwise it can be treated on an outpatient basis
● IV Fluids
● Broad Spectrum Antibiotics (same as appendicitis):
- fluroquinolone + metronidazole
- TMP-SMX + metronidazole
- amoxicillin - clavulanate (Augmentin)
● if signs of peritonitis ➙ emergency exploration thru midline incision

Front 62

A 65yo F that presented to the ER with severe abdominal pain is found to have leukocytosis and an abscess in the region of the sigmoid colon. What is the most likely predisposing lesion, and what is the next step in management?

Back 62

● diverticulosis ➜ diverticulitis ➜ abscess
● Next step: CT-guided or U/S guided percutaneous drainage
● IV antibiotics

Front 63

What are the classic features of carcinoid syndrome?

Back 63

"B FDR"
● Bronchospasm (10-20%)
● Flushing (85%)
● Diarrhea (80%)
● Right-sided valvular disease/ murmurs

Front 64

What is the treatment for carcinoid syndrome?

Back 64

● somatostatin analog such as octreotide
● other drugs that can be used for symptom relief:
- Cyproheptadine (5-HT1 antagonist) for diarrhea and/or anorexia
- Albuterol and/or theophylline for asthma symptoms
- Codeine and/or cholestyramine for diarrhea
● if symptoms are refractory to octreotide ➜ INFα combined with hepatic artery embolization
● surgical resection in certain circumstance of isolated tumors
● valvular surgery for symptomatic carcinoid heart disease

Front 65

What are the risk factors for diverticulosis?

Back 65

age >60yrs
low fiber
high fat diet

Front 66

What is the treatment for mild diverticulitis?

Back 66

● can be treated as an outpatient
● Broad spectrum ABX that cover gram negs & anaerobes:
- Fluoroquinolones + MEtronidazole
- TMP-SMX (Bactrim) + Metronidazole
- Amoxicillin + Clavulonate (Augmentin)
● Bowel rest for 3 days

Front 67

What is the treatment for diverticulitis with abscess formation?

Back 67

- CT guided or U/S guided percutaneous drainage
- IVF, bowel rest, antibiotics

Front 68

Which type of hemorrhoids are painful, and where are they located?

Back 68

Type ➜ external hemorrhoids
Location ➜ distal to dentate/pectinate line

Front 69

What is the treatment for hemorrhoids?

Back 69

Sitz baths
High fiber diet, adequate hydration
avoid excessive straining
ligation with rubber bands
sclerotherapy
surgery/excision
I&D

Front 70

What do you call an abnormal tract btw a hollow viscus (such as the bowel) and the perianal skin?

Back 70

Fistula-in-ano

Front 71

How can a carcinoid tumor be localized?

Back 71

CT Scan or octreotide scan

Front 72

Fever + LLQ pain

Back 72

think Diverticulitis

Front 73

What are the current colon cancer screening recommendations for normal risk patients?

Back 73

For the average risk pt, the following screening should start at AGE 50:
● fecal occult blood test (FOBT) ANNUALLY with stool guaiac (samples from 3 consecutive stools is ideal)
● Colonoscopy every 10 years (or flex sig and double-contrast barium enema every 5 yrs)
● (CT colonography is NOT currently used for screening b/c it does not have adequate sensitivity & specificity)

Screening should stop when a pt's life expectancy is <5yrs (or at age 75, whichever comes first)

Front 74

A 20yo pt with a strong FHx of colon cancer is found to have an Aut Dom mutation in the APC gene. What prophylactic measures should this pt take to prevent future morbidity & mortality?

Back 74

Patients with familial adenomatous polyposis (FAP) have a 95-100% chance of developing colorectal cancer. Prophylaxis includes:
● Flexible sigmoidoscopy or colonscopy every 1yr starting at age 10 ➜ when multiple adenomas are identified, then colectomy is indicated (if no adenomas are identified, then continue annual flex sig thru age 40 then q3-5years)
● Colectomy when adeonmas identified (abdominal colectomy, mucosal proctectomy, and ileoanal anastomosis)
● Upper GI endoscopy at the time of colectomy (or early 30s) then q3-5 yrs if no lesions are seen

Front 75

Whats the recommendation for f/u colonoscopy for pts with history of 1-2 tubular adenomas <1cm?

Back 75

repeat colonoscopy in 5 yrs

Front 76

Whats the recommendation for f/u colonoscopy for pts with history of 2 or more tubular adenomas?

Back 76

repeat colonoscopy in 3 years

Front 77

Whats the recommendation for f/u colonoscopy for pts with history of tubular adenomas >1cm

Back 77

repeat C-scope in 3 yrs

Front 78

Whats the recommendation for f/u colonoscopy for pts with history of Villous adenoma or high-grade dysplasia ?

Back 78

repeat C-scope in 3 yrs

Front 79

Whats the recommendation for f/u colonoscopy for pts with family history of colon cancer?

Back 79

repeat C-scope in 3 years

Front 80

Whats the recommendation for f/u colonoscopy for pts with history of >2cm sessile polyp

Back 80

repeat C-scope in 3-6 months

Front 81

Whats the recommendation for f/u colonoscopy for pts that had a poor prep, so the cecum was not able to be seen during the first colonoscopy?

Back 81

repeat C-scope <3yrs

Front 82

Whats the recommendation for f/u colonoscopy for pts with history of more than 10 adenomas?

Back 82

repeat C-scope <3yrs

Front 83

Which type of colonic polyps are precancerous?

Back 83

Tubular adenomas
Tubulovillous adenomas
Villous adenomas

NOTE: hyperplastic polyps are NOT precancerous

Front 84

During a routine exam, a 70yo M is found to have a new-onset iron-deficiency anemia. What should you suspect and investigate further?

Back 84

Suspect colon cancer

next steps: stool guaiac & colonoscopy

Front 85

A patient with colon cancer has local lymph node involvement without distal mets. What stage of cancer is this?

Back 85

Stage 3 (will need chemotherapy)

Front 86

What tumor marker is used in colon cancer patients?

Back 86

CEA

Front 87

At what intervals will a post-colon cancer resection pt need colonscopy?

Back 87

at 1 yr then 3 yrs then every 5 yrs

Front 88

What gene is responsible for familial adenomatous polyposis (FAP)?

Back 88

mutation in APC gene

Front 89

In what condition does the pt have intestinal polyps that are hamartomas, and pigmentation of the lips, oral mucosa, hands and genitals?

Back 89

Peutz-Jeghers Syndrome

Front 90

At what age should colon cancer screening begin?

Back 90

- all pts at age 50yrs
- if pt has first degree relative with colon cancer, start 10 yrs before the relative age of diagnosis

Front 91

What is the recommendation for colon cancer screening by fecal occult blood testing (FOBT)?

Back 91

annually

Front 92

What is the recommendation for colon cancer screening by flexible sigmoidoscopy + double contrast barium/air enema?

Back 92

every 5 yrs

Front 93

What is the recommendation for colon cancer screening by colonoscopy?

Back 93

every 10 years

Front 94

what are the next steps in the management of a pt that presents to the ER with massive lower GI bleeding?

Back 94

(1) Assess & Stabilize
- Hx & PE
- Continuous monitor of vital signs
- Obtain IV access with 2 large bore IV's (18-gauge in both arms) or central line
- Blood volume resuscitation with NS or LR as needed
- Type & cross 2units pRBCs
- Labs: CBC, coags (guaiac stool if necessary to confirm blood)

(2) treat & determine cause
- NGT lavage to r/o massive GI bleed
- Surgery consult for admission (colonoscopy, +/- surgical intervention)
- if colonoscopy is nondiagnostic & not feasible (ie too much active bleeding may obscure visualization) and bleeding persists ➜ radionucleotide scan and/or angiogram

Front 95

How to assess volume status in bleeding pts?

Back 95

Blood pressure
Urine output
Heart rate

Front 96

What is a HIDA scan (aka cholescintigraphy)?

Back 96

- technetium labeled hepatic iminodiacetic acid (HIDA) given IV ➜ taken up by hepatocytes ➜ excreted into bile ➜ visualization of gallbladder
- inability to visualize gallbladder with this test indicates cystic duct obstruction usually from acute cholecystitis or an obstructing stone

Front 97

What are the common etiologies of UPPER GI bleeds?

Back 97

- Peptic Ulcer Disease (PUD)
- Esophageal varices
- AVM
- Tumors
- Esophageal erosions
- Mallory Weiss Tears

Front 98

What are the most common causes of LOWER GI bleeds?

Back 98

-Diverticulosis or Diverticulitis
- Bowel Ischemia
- hemorrhoids or anal fissures
- neoplasms
- polypectomy

Front 99

A pt in the ER has just thrown up his second basin full of blood. He is drunk and tachycardic. What is the next step in managing this pt?

Back 99

IV fluid resuscitation

Front 100

What are the risk factors for cholelithiasis?

Back 100

Fat, Female, Forty, Fertile, Family Hx

Front 101

What are the key features of the history of a pt with cholelithiasis?

Back 101

- Postprandial RUQ pain & discomfort
- nausea & maybe vomiting
- worse after fatty or heavy meals

Front 102

How is the HIDA scan used?

Back 102

to show failure of the gallbladder to fill ➜ obstruction of the cystic duct
ability to fill but not empty ➜ dyskinesia, due to chronic cholecystitis

Front 103

What lab value is reliably elevated in the case of bile duct obstruction?

Back 103

alkaline phosphatase

Front 104

What is the term for a stone caught in a bile duct?

Back 104

choledololithiasis

Front 105

A pt has an abdominal xray taken as part of an ER workup. The radiologist noted that the pt's gallbladder appears calcified. What is the next step?

Back 105

calcified gallbladder aka "porcelain" gallabladder

think CANCER! - remove the gallbladder (its too hard to biopsy)

Front 106

HYQ: what is the next step in management of a pt younger than 50 with minimal bright red blood per rectum (ie only seen on the toilet paper after wiping)?

Back 106

anoscopy (looking for hemorrhoids)

Front 107

HYQ: What is the most likely cause of acute pain and swelling of the midline sacrococcygeal skin & subcutaneous tissues?

Back 107

Pilonidal cyst

Front 108

What is the most likely cause of recurrent LLQ abdominal pain that improves after defecation?

Back 108

Diverticulosis

Front 109

What type of pt is at high risk of acalculous cholecystitis?

Back 109

Pts on TPN or in the ICU

Front 110

What is charcot's triad? Reynold's pentad?

Back 110

Charcot's triad: Fever + RUQ pain + Jaundice
Reynolds Pentad: Fever/RUQ Pain/Jaundice + mental status changes + hypotension

Front 111

How does the interventional component of treatment of cholecystitis differ from that of cholangitis?

Back 111

cholecystitis ➜ choleystectomy
cholangitis ➜ ERCP, then cholecystectomy

Front 112

A 60yo M undergoes colonoscopy and is found to have 3 small tubular adenomas that are completely removed. When should he undergo his next colonoscopy?

Back 112

3 yrs

Front 113

A 40yr M tells you his father had colon cancer at age 55. When should this man's first colonoscopy be scheduled?

Back 113

45 yrs

Front 114

What antibiotic combinations are used in the treatment of diverticulitis as an outpatient?

Back 114

(1) TMP-SMX (Bactrim) + metronidazole
(2) Fluoroquinolone + Metronidazole
(3) Amoxicillin + clavulonate (Augmentin)

Front 115

How are anal fissures managed?

Back 115

- stool softeners & topical nitroglycerine
- topical nifedipine, bethanecol, diltiazem
- Botox
- Partial sphincterectomy

Front 116

How is volume status assessed in a pt with a GI bleed?

Back 116

HR, BP & urine output

Front 117

What is the treatment for hepatic encephalopathy?

Back 117

● identify & correct the underlying precipitating factors (hypovolemia, GI bleeding, hypoxia, infection)
● Lactulose titrated to 2 soft bowel mvmts a day (causes osmotic diarrhea)
● Neomycin or rifaximin antibiotics to reduce toxins formed by gut bacteria
● Protein restriction to decrease nitrogen/ammonia related toxins

Front 118

What are the signs and symptoms of Budd-Chiari syndrome?

Back 118

Budd-Chiari is the thrombosis and occlusion of the hepatic vein or hepatic stretch of the inferior vena cava (IVC) and presents with:
● ascites (84%)
● hepatomegaly (76%)
● Jaundice
● acute presentation: acute RUQ pain + hepatomegaly, and rapid development of jaundice and ascites
● subacute or chronic presentation: gradual development of ascites, LE edema, cirrhosis, and portal hypertension over a few months
● eventual development of liver failure and hepatic encephalopathy

Front 119

What criteria compose the Child's classification of operative mortality in pts with liver disease?

Back 119

"A BEAN"
Ascites
Bilirubin
Encephalopathy
Albumin
iNr

Front 120

What is the treatment for SBP (Spontaneous Bacterial Peritonitis)?

Back 120

● Cefotaxime (2g IV q8hrs), ceftriaxone or other 3rd Gen Cephalosporin for at least 5 days to cover for gut bacteria (E. coli, Klebsiella, enterococcus), and Staph/ Strep
● Albumin dosed IV (1.5g/kg at diagnosis then 1g/kg on day 3) maintains plasma volume ➔ preserves renal function ➔ reduces renal impairment and mortality

Front 121

How can alcohol-induced fatty liver disease be reversed?

Back 121

stop drinking alcohol

Front 122

What is the name of the disease where there is thrombosis of the hepatic vein or hepatic portion of the inferior vena cava (IVC)?

Back 122

Budd-Chiari Syndrome

Front 123

How is the liver different in Budd Chiari vs Cirrhosis?

Back 123

SIZE is the difference
Budd-Chiari = large liver
Cirrhosis = small liver

Front 124

What antibiotics can be used to treat spontaneous bacterial peritonitis (SBP)?

Back 124

Cefotaxime
3rd Gen Cephalosporins

Front 125

What lab values will help to make the diagnosis of SBP?

Back 125

● PMNs >250
● glucose <50mg/dL
● total protein >1g/dL
● LDH > normal serum LDH

Front 126

What is the medical treatment for varices?

Back 126

beta-blockers
vasopressin
octreotide

Front 127

What 2 diuretics are used in conjunction for the treatment of ascites/ portal hypertension?

Back 127

Furosemide
Spironolactone

Front 128

What is the surgical procedure used as a temporizing measure for severe portal hypertension?

Back 128

TIPS - tranjugular intrahepatic portacaval shunt

Front 129

What PE and lab findings would lead you to suspect Primary Biliary Cirrhosis as a diagnosis?

Back 129

- Usually women (95% of pts) btw ages 30-65
- Fatigue & pruritis are the most common presenting sxs
- Excessive daytime somnolence
- Pruritis often starts during pregnancy but is not relieved postpartum
- Pts are often initially referred to a dermatologist for pruritis and excoriations are common
- Skin changes: hyperpigmentation due to melanin deposition (25-50%), xerosis (70%), dermatographism (57%)
- Xanthelasma (cholesterol-filled plaques on the medial aspects of the eyelids bilaterally and/or xanthoma
- Hepatomegal that progressively worsens +/- splenomegaly
- Malabsorption and steatorrhea from less bile acid secretion
- Cirrhosis, jaundice, ascites, edema, portal hypertension occur in late stage disease
- Labs: ↑ alk PO43- & ↑ GGT, ↑ serum direct & indirect bili (but not in early disease) ↑ cholesterol
- ↑ serum antimitochondrial Abs (>95% of pts) – THE HALLMARK FINDING OF PBC
- ↑ ANA (70%)
- assoc conditions: other autoimmune disorders (ie thyroiditis/hypothyroid, sicca syndrome, scleroderma, Sjogren’s, arthritis, Raynaud’s), osteoporosis, osteomalacia

Front 130

What is the treatment for Primary Biliary Cirrhosis (PBC)?

Back 130

● Ursodeoxyxholic acid (UDCA) – delays disease progression and enhances survival → the ONLY approved therapy for PBC
● If UDCA not sufficient → may add colchicine +/- methotrexate
● If pruritis → cholestyramine
● Prevention of metabolic bone disease:
- Calcium 1,500 mg/d + at least 800 IU of Vit D daily
- Supplement vitamins A & D as needed based on annual serum levels of these vitamins
- Evaluation with bone DXA scan at the L-spine and hup
● If low bone density → bisphosphonates
● If esophageal varices → β-blocker +/- band ligation +/- surgical intervention (splenorenal shunt or TIPS)
● If iron deficiency anemia → oral iron replacement
● If fatigue → modafinil (not well studied)
● Dietary changes:
- If steatorrhea → reduce dietary fat
- If weight loss → supplement medium-chain triglycerides which do not need bile for absorption
- If pancreatic insufficiency → pancreatic enzyme replacement
● Treat hypOthyroidism as needed
● If painful or debilitating xanthomas on pals or soles, large volume plasmapheresis q 1-2wks to normalize serum cholesterol
● Definitive treatment is LIVER TRANSPLANT

Front 131

What are some of the possible etiologies of secondary sclerosing cholangitis?

Back 131

Intraductal biliary stones
Durgical trauma or blunt abdominal trauma to the biliary tree
Drugs (IV Chemotherapy)
Recurrent pancreatitis
Autoimmune pancreatitis
AIDS cholangiopathy

Front 132

What are the risk factors, signs/symptoms of and treatment for hepatic adenoma?

Back 132

Most often in females 20-44 (OCP years)
Risk factors: OCP use, anabolic steroids, (glycogen storage disease types I and III)
S/S: RUQ pain, but usually there are no symptoms b/c it is often an incidental finding on imaging
Malignant transformation in 10% of pts
Tx: d/c OCP, serial imaging & AFP +/- resection (esp if >5cm)

Front 133

What is the screening lab for hemochromatosis?

Back 133

Serum ferritin

Front 134

What are some key clues to the diagnosis of hemochromatosis?

Back 134

Bronze skin
Symptoms of Diabetes
Cardiac insufficiency
Abdominal pain
Hepatomegaly
Arthalgias

Front 135

How is excess copper secreted from the body?

Back 135

Thru the bile

Front 136

Where does excess copper deposit and what symptoms does that cause?

Back 136

CNS: psychiatric disturbance, loss of coordination, tremor
Cornea: Kayser Fleischer rings
Liver: hepatomegaly

Front 137

What cooper-related lab value would you order in a pt suspected of having Wilson disease?

Back 137

Serum ceruloplasmin level

Front 138

What agents would be used to treat Wilson disease?

Back 138

Penicillamine
Trientine
Zinc
Vit B6

Front 139

What is the primary treatment for PBC?

Back 139

Ursodeoxycholic acid, colchicine, methotrexate
Liver transplant

Front 140

What are the key differences btw PBC & PSC?

Back 140

see above

Front 141

What are the important characteristics of Gilbert’s disease?

Back 141

Mild deficiency of glucuronosyltransferase
Mild jaundice
Indirect bilirubin <5
No treatment

Front 142

Crigler-Najjar Syndrome Type I causes severe disease and often death b/c of the severe deficiency of what enzyme?

Back 142

Glucouronosyltransferase (aka uridine diphosphate glycosyltransferase (UGT))

Front 143

What is the serum marker for hepatocellular carcinoma (HCC)?

Back 143

α-fetoprotein (AFP)

Front 144

What are the “rule of 2’s” for Meckel’s Diverticulum?

Back 144

Def: remnant of vitelline duct, exists as outpouching of ileum, may contain ectopic tissue
Males 2x more common vs females
w/in 2ft of ileocecal valve
2 types of ectopic tissue (gastric or pancreatic)
found in 2% of population
most complications occur before 2 yrs old

Front 145

What is the differential for Neonatal Jaundice? (HIGH YIELD!)

Back 145

- Physiologic jaundice: (50% of newborns) – starts day 2-3, peaks at <10mg/dL on day 3-5
- Exaggerated physiologic jaundice (aka breastfeeding jaundice) – occurs in 1st wk of life, peaks at 12-15mg/dL, due to dehydration → make sure baby has more than 10 feeds/day
- Breast milk jaundice: starts days 4-14 (usually after 1st wk) due to substances in breast milk. May continue for wks-mos while breastfeeding. Improvement with the substitution of formula for 48-72 hrs is diagnostic
- Immune related:
- ABO incompatibility
- Rh (or other antigen) incompatibility (erythroblastosis fetalis)
- Trauma, cephalohematoma, bruising
- Infection/sepsis (look for signs of infxn such as fever, lethargy, and poor feeding)
- Polycythemia
- Hereditary disease
- G6PD deficiency (more common in black, African, Asian, Mediterranean, and Middle-Eastern males)
- Hereditary spherocytosis
- Dubin-Johnson (direct/conjugated bili elevation)
- Rotor’s (direct/conjugated bili elevation)
- Byler’s (direct/conjugated bili elevation)
- Biliary atresia: may present after 2wks of age with jaundice and pale stools. Direct bili is more than 20% of the total bili which is usually elevated to 6-12 mg/dL. Early referral to Ped GI for diagnosis (U/S + biliary nuclear imaging +/- biopsy) is important since surgical repair prior to 2 months of age is essential in preventing biliary cirrhosis

Front 146

What antibiotic is contraindicated in neonates with hyperbilirubinemia & why?

Back 146

Ceftriaxone (displaces bilirubin from albumin)

Front 147

What characteristics might help you identify newborn jaundice as pathological?

Back 147

Any jaundice in 1st 24hrs
Rise in total bili by more than 0.5mg/dL/hr
Rise in total bili more than 5mg/dL/day
Direct (conjugated) hyperbili greater than 20% of the total bili or >1.5 mg/dL
Total bili higher than 13mg/dL in term neonates
Jaundice appearing after 2-3 wks of age

Front 148

What are the criteria for failure to thrive (FTT) in a child younger than 2rs of age?

Back 148

Weight <3rd or 5th percentile for gestation corrected age on more than one occasion (make sure to use special growth chart for Down syndrome and Turner syndrome pts)
Weight <80% of ideal weight for age
Weight crosses 2 major percentiles downward on a standardized growth chart over time
Weight for length ratio <10th percentile
Rate of daily weight gain less than that expected for age

Front 149

What would be the common presentation of tracheoesophageal fistula (TE fistula)?

Back 149

Infant that coughs or aspirates during feeds
abdominal distention

Front 150

What are the key characteristics of the H&P of a pt with pyloric stenosis?

Back 150

1-2wk old infant
projectile non-bilious vomiting
palpable mass in epigastric area

Front 151

What is seen on biopsy of the colon in a Hirschsprung pt?

Back 151

Absence of enteric ganglia

Front 152

What are key characteristics in the H&P of a child with intussusception?

Back 152

Currant jelly stool
Sausage-like abdominal maa
Barium enema (shows obstruction & may reduce defect)

Front 153

What study can be used to diagnose a 2yo child with painless rectal bleeding?

Back 153

Meckel’s scan (think Meckel’s diverticulum)

Front 154

What characteristics might help you identify newborn jaundice as pathological?

Back 154

Any jaundice in the 1st 24hrs is pathological
Rise in bilirubin: >0.5/hr, >5mg/day
Direct (conjugated) bili: >20% of total bili or >1.5mg
Total bili: >13 mg in full-term neonates
Jaundice appearing after 2-3wks of age

Front 155

What is the name of the sign & what condition is it associated with:
Deep palpation of RUQ → arrest of inspiration due to pain

Back 155

Murphy's sign - Cholecystitis

Front 156

What is the name of the sign & what condition is it associated with:
fever, jaundice, RUQ Pain, hypotension, AMS

Back 156

Reynolds pentad - Cholangitis

Front 157

What is the name of the sign & what condition is it associated with:
RLQ pain on passive extension of the hip

Back 157

Psoas sign - Appendicitis

Front 158

What is the name of the sign & what condition is it associated with:
RLQ pain on passive internal rotation of the flexed hip

Back 158

Obturator Sign - Appendicitis

Front 159

What is the name of the sign & what condition is it associated with:
LUQ pain and referred left shoulder pain

Back 159

Kehr's sign - Splenic Rupture

Front 160

What is the name of the sign & what condition is it associated with:
Ecchymosis of the skin overlying the flank

Back 160

Grey Turner's sign - Pancreatitis

Front 161

What is the name of the sign & what condition is it associated with:
Ecchymosis of skin overlying the periumbilical area

Back 161

Cullen's Sign - Pancreatitis

Front 162

What is the tx for hepatic encephalopathy?

Back 162

Lactulose
Neomycin/ rifaximin
Protein restriction

Front 163

What are the symptoms of Budd-Chiari syndrome?

Back 163

Ascites
Hepatomegaly
Jaundice
+/- RUQ pain
Liver failure

Front 164

What is the most widely used screening test for hemochromatosis?

Back 164

Phlebotomy (weekly or biweekly until normal Hct, then 1/mo)
Rarely deferoxamine

Front 165

What distinguishes primary biliary cirrhosis (PBC) from primary sclerosing cholangitis (PSC)?

Back 165

PBC → women, AMA & ANA, other autoimmune disease

PSC → men, pANCA, ulcerative colitis, “beads on a string” on ERCP

Front 166

What is the treatment for primary biliary cirrhosis?

Back 166

Ursodeoxycholic acid, colchicine
May need transplant

Front 167

What is the tumor marker for hepatocellular carcinoma? For colon cancer? For gastric cancer? For pancreatic cancer?

Back 167

HCC → α-fetoprotein (AFP)
Colon Cancer → CEA
Gastric Cancer → CEA
Pancreatic Cancer → CEA & CA 19-9
Ovarian Cancer → CA-125

Front 168

What is the most common type of TE fistula?

Back 168

Blind upper esophageal pouch
Lower esophagus attached to trachea

Front 169

What is the classic presenting scenario for necrotizing enterocolitis?

Back 169

Premature or low birth weight infant → then started on tube feeds → subsequently to starting the tube feeds, develop increasing abdominal distention & signs of enterocolitis