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406 Cards in this Set
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Dysphagia: first question to ask
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liquids, solids, or both?
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Hard to drink liquids (choking/gagging/nasal regurgitation). Swallow solids ok. What type of Dysphagia? (General rule of thumb)
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Oropharyngeal
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Starts with difficulty swallowing solids, but drinking liquids ok. What type of dysphagia? (General rule of thumb)
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Esophageal Obstruction
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Hard to swallow solids and liquids. What type of dysphagia? (General rule of thumb)
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Esophageal Motility
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Diagnostic test for oropharyngeal dysphagia.
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Cine-Esophagram (swallow study with speech therapy)
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1st study to order if suspecting Esophageal Dysphagia (Obstruction or Motility).
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Barium Swallow
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Muscular or Neurologic pathology causing dysphagia. What type of Dysphagia?
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Oropharyngeal
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Esophageal Obstruction suspected cause of dysphagia; what test follows Barium Swallow?
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EGD with bx
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Motility Disorder suspected as cause of Dysphagia; what study follows Barium Swallow?
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Manometry
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Odynophagia (pain with swallowing); what study to order if no obvious cause?
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EGD
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Intermittent obstructive esophageal dysphagia. name 2 causes.
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Esophageal ring (schatzki) and Eosinophilic esophagitis
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Candidal Esophagitis. Pathognomonic for what?
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AIDS
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Intermittent Esophageal Dysmotility. Diagnosis?
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Esophageal spasm
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Most common Esophageal Motility Disorder?
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Achalasia
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Man with progressively worsening dysphagia. Started with difficulty with solids, now has trouble with liquids. Diagnosis?
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Esophageal Cancer until proven otherwise
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Progressive Dysphagia with GERD sx: name 2 diagnoses.
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Scleroderma (motility) and Peptic Stricture (obstructive)
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Bird's beak on barium swallow. Diagnosis?
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Achalasia
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Retinitis, Colitis, and Esophagitis. Infectious agent?
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CMV
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Treatment for CMV esophagitis?
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Ganciclovir IV
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Treatment for HSV esophagitis?
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Acyclovir IV
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Treatment of Oral Thrush
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Fluconazole PO
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Plummer-Vinson Syndrome triad.
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Dysphagia (2/2 Esophageal Web)
Glossitis (swelling tongue) Iron Deficiency Anemia |
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Corkscrew esophagus or Nutcracker esophagus: dx?
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Diffuse Esophageal Spasm (DES)
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Treatment for "Chest" Pain 2/2 esophageal dysphagia.
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Nitrates and CCB (symptomatic tx)
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If nitrates and CCBs fail to control esophageal spasm pain, what is tx?
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surgery (myotomy)
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Impaired relaxation of the Lower Esophageal Sphincter (LES). Dx?
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Achalasia
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Why is peristalsis lost from only distal 2/3s of the esophagus in Achalasia?
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top 1/3 is skeletal muscle
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Regurgitation of food eaten yesterday. Dx?
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Achalasia
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Why use manometry to confirm Achalasia with bird's beak Barium Swallow?
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malignancy can obstruct at lower esophagus and mimic achalasia
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1st line treatment of Achalasia.
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pneumatic balloon dilation
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When is repeated botulinum toxin therapy indicated in Achalasia?
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if concerned esophagus will rupture (more risk in elderly) with balloon dilation
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Second most common esophageal dysmotility disorder (after Achalasia).
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Esophageal diverticula (e.g. Zenker's)
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Even though most esophageal diverticula are diagnosed incidentally via EGD, what is the diagnostic of choice and why?
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Barium Swallow preferred secondary to risk of perforation when scope cannalates the diverticulum
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Most common Esophageal cancer worldwide
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Squamous Cell Carcinoma
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Most common Esophageal cancer in the U.S.
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Adenocarcinoma
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Major risk factors for Squamous Cell Carcinoma.
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Smoking and Alcohol
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Major risk factor for Adenocarcinoma of the Esophagus.
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Barrett's secondary to GERD
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Rapid onset of dysphagia with weight loss. Diagnosis?
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Cancer until proven otherwise
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What must happen during EGD when evaluating obstructive esophageal dysphagia?
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biopsy (to rule/out cancer etc.)
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Transient Lower Esophageal Sphincter (LES) relaxation. Dx?
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GERD
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Heartburn without Dysphagia. Likely Dx?
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GERD
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Management of patient with 1st presentation of heart burn
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Empiric PPI and/or H2 blocker
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Why perform barium swallow when you suspect GERD?
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to look for hiatal hernia as source
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Why is manometry often performed on GERD patients?
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to aid placement of pH probe
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When to order EGD in GERD sx? (3 reasons)
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if unresponsive to empiric therapy
if long standing sx (check for barrett's) if any concerning sx (e.g. dysphagia) |
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How often to screen patients with GERD for Barrett's esphagus (with EGD)?
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q5-7 years
|
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If Barrett's esophagus is found on EGD, but no adenocarcinoma, when is next EGD screening?
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3 years
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Lifestyle advice to aid GERD symptoms.
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Graze (small meals more often)
Eating at night prohibited Raise head-of-bed Diet (weight loss) |
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What surgery for refractory GERD (especially for sliding hiatal hernias)?
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Nissen fundoplication
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Empiric medications for GERD sx.
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H2 blocker (cimetidine or ranitidine)
PPI (omeprazole or lansoprazole) |
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95% of hiatal hernias are sliding; 5% are paraesophageal. What is a paraesophageal hernia?
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fundus of stomach herniates through next to esophagus
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Which of the 2 types of hiatal hernias needs surgical gastropexy? why?
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paraesophageal (prevent gastric volvulus)
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GERD vs. Gastritis: where is the pain?
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GERD: chest
Gastritis: epigastric abd |
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Type A gastritis in the fundus (10% of gastritis) is due to what?
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autoantibodies to parietal cells
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Parietal cells secrete what that aids with B12 absorption?
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intrinsic factor
|
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What is the anemia called 2/2 autoimmune caused B12 deficiency?
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pernicious anemia
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Top 2 causes of gastritis.
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NSAIDS and H. pylori
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Meds for GI ulcer/gastritis prophylaxis in ICU patients (and becoming standard of care for all inpatients).
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H2 blocker or PPI (usually omeprazole)
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Gastric cancer that matastasizes to the ovary.
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Krukenberg tumor
|
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Triple therapy for H. pylori induced gastritis or PUD.
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Amoxicillin, Clarithromycin, Omeprazole 10-14 days
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Patient with epigastric pain: when is EGD indicated? (3 reasons)
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age over 55
any alarm sx (e.g. bleeding) failed empiric PPI |
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When to perform 24 hour pH probe in patient with heartburn.
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If EGD is negative for GERD and symptoms persist despite trial of PPI/H2.
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Gastric cancer is common in what 2 countries?
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Korea and Japan
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Early satiety and dyspepsia. Feared diagnosis?
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Gastric Cancer
|
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Virchow's node (supraclavicular lymph node) is associated with what cancer?
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Gastric Cancer
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Gastric Cancer that presents with upper GI bleeding (advanced cancer) has what five-year survival?
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less than 10%
|
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Most common cause of PUD.
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H. pylori
|
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Dull, burning epigastric pain that changes with meals. Diagnosis?
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PUD
|
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Duodenal vs. Gastric ulcer: worse or better with meals?
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Duodenal: Decreases with meal
Gastric: Greater with meal |
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Coffee-ground hematemesis or melena. Where is the bleeding?
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upper GI
|
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Patient with epigastric tenderness in ER: imaging to order and why?
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AXR to r/o perforation
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Age above which any patient with epigastric pain will get EGD?
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55
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Young patient with epigastric pain with no alarm symptoms. Next 2 steps in assessment?
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1) urease breath test or h. pylori stool antigen test
2) check for bleed (CBC, NG lavage, stool guaiac) |
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Patient on treatment for PUD suddenly becomes unstable; likely cause?
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perforation
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PUD patient now with hematochezia; likely mechanism of ulcer bleed?
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hemorrhage from artery erosion
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PUD patient with arthritis. What to give instead of NSAIDS?
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Misoprostol
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PMHx is important when assessing epigastric pain (for NSAIDS); why is PSocHx important?
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EtOH and Tobacco are risk factors for PUD
|
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For epigastric pain, EGD is needed if empiric H2/PPI fails. How long to try it?
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2 months
|
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What other test to order (with EGD) if empiric H2/PPI fails to control GERD (or Gastritis, or PUD)? Why?
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Gastrin level to r/o Zollinger-Ellison syndrome
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What is Zollinger-Ellison Syndrome?
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Gastrin producin tumor in duodenum or pancreas.
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What endocrine syndrome are Zollinger-Ellison gastrinomas associated with (20%)?
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MEN 1
|
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Scan with this radiolabeled drug can localize gastrinoma in Zollinger-Ellison syndrome.
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Octreotide Scan
|
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1st line medical therapy for gastrinoma in Zollinger-Ellison syndrome to control symptoms.
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PPI (H2 blocker typically ineffective)
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Preferred (definitive) treatment for gastrinoma of Zollinger-Ellison?
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surgical resection (metastatic risk)
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Most common cause of diarrhea worldwide.
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Rotovirus
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Diarrhea: child under 5
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Rotovirus
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Diarrhea: recent antibiotics.
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C. diff
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Diarrhea: recent travel
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E. coli
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Diarrhea: recent camping trip
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Giardia
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Diarrhea: Shellfish
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vibrio parahemolyticus
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Diarrhea: Cruise ship
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Norovirus
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Diarrhea: uncooked hamburger
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e. coli O157:H7
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Diarrhea: poultry
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Campylobacter or Salmonella
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Diarrhea: raw eggs or dairy (egg shell)
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salmonella
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Diarrhea: mayonnaise (picnics)
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S. aureus
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Diarrhea: bloody (4)
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Salmonella, E. coli, Shigella, Campylobacter
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Most common cause of infectious diarrhea in the U.S.
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Campylobacter
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Treatment of Campylobacter
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Erythromycin (if any)
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Treatment of C. diff.
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Metronidazole or Vancomycin
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Recent undercooked hamburger with bloody diarrhea. Why not treat with antibiotics?
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e. coli O157:H7 is likely cause, and antidiarrheal therapy can induce HUS
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Salmonella diarrhea in sickle cell patient: possible complication?
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Salmonella Osteomyelitis
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Medication to avoid in patients with Entamoeba Histolytica 2/2 perforation risk.
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steroids
|
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Treatment for Shigella diarrhea to decrease spread.
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TMP-SMX
|
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What is the infectious dose of Shigella?
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1-10 organisms (very contagious)
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What is the mechanism of death 2/2 acute diarrhea (especially in 3rd world)?
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dehydration
|
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If diarrhea lasts this many days, work-up is indicated.
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more than 5 days
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First 2 tests to order in acute diarrhea work-up.
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Stool guaiac and Fecal Leukocytes
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When to decide to work up acute diarrhea.
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clinical judgement: dehydration, fever, over 5d, mucus, pus, blood, foreign travel, recent hospitalization/abx use
|
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Diarrhea and recent foreign travel. What is the confirmatory test for E. histolytica?
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ELISA
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When do you need to order Stool Cx or O&P in work-up for acute diarrhea in order to be cost effective?
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under 72 hours from admit
|
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Why do antibiotics cause diarrhea?
|
change bowel flora
|
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3 diet supplements that causes of diarrhea.
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Sweeteners (sorbitol or lactulose)
Minerals (Mg) Tea (Senna) |
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Loperamide mnemonic.
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I'lL OPERAte MI Diarrhea
|
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2 causes of constipation post-op.
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Ileus and Opiods
|
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4 causes of Malabsorbtive Diarrhea.
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Bile Salt Deficiency, Pancreatic Insufficiency, Mucosal abnormalities (Sprue), and Lactose intolerance
|
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3 step evaluation for chronic diarrhea which cannot be clinically confirmed.
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1) Fecal Leukocytes and Guaiac
2) Stool Cx and O&P 3) Osmotic Gap and Fecal Fat |
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2 reasons for chronic diarrhea to rule/out before work-up.
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Lactose intolerance and Medication induced
|
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When to do Colonoscopy for acute or chronic diarrhea (2 reasons)?
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1) positive leukocytes or guaiac and negative culture
2) all work up is negative |
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Osmotic gap which indicates malabsorption diarrhea.
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over 50
|
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Screening and confirmatory tests for Celiac Sprue.
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Screen: TTG
Confirm: biopsy (with EGD) |
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Why check IgA levels with TTG for Celiac screening?
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IgA deficiency can cause a false negative screen.
|
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Why confirm positive TTG screen with biopsy?
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Giardia can cause false positive
|
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Lifestyle modification as a test in the work-up for diarrhea (especially malabsorption).
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any changes with fasting?
|
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Over the counter treatment for mild diarrhea.
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Pepto Bismol (Bismuth Subsalicylate)
|
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Treatment for Celiac Disease?
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Gluten free diet
|
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4 deficiencies commonly associated with Celiac Disease.
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Fe, Folate, Ca, Vit D
|
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If patient does not give classic lactose intolerance history, what test to order?
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Hydrogen breath test following lactose load
|
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Why does carcinoid syndrome suddenly appear when after metastasis?
|
prior to liver metastasis, hormones undergo extensive first pass metabolism
|
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Carcinoid syndrome pentad.
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Cutaneous flushing
Abdominal cramps Respiratory wheeze Cardiac valve lesions i n o i Diarrhea |
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Diagnostic test for carcinoid syndrome.
|
urine serotonin metabolite test (5-HIAA)
|
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Treatment of carcinoid syndrome.
|
Octreotide (for sx control) and surgery
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Alternating constipation and diarrhea; abdominal pain relieved by bowel movement. Diagnosis?
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IBS
|
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What often happens during sleep which is a clue to IBS?
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nothing happens
|
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3 causes of increased fecal fat and increased osmotic gap.
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malabsorption, pancreatic insufficiency, and bacterial overgrowth
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Confirms pancreatic insufficiency as the source for diarrhea.
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secretin stimulation test
|
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Confirms bacterial overgrowth as a source for diarrhea.
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C-xylose breath test
|
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If work-up is all negative for diarrhea, what 24 hour stool weight indicates likely secretory cause?
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over 1000 g
|
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Miracle drug for diarrhea and constipation.
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Fiber
|
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What antispasmodics to remember for treatment of IBS.
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dicyclomine or hyoscyamine (anticholinergics)
|
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Leading cause of Small Bowel Obstruction (SBO) in kids.
|
hernia
|
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Leading cause of Small Bowel Obstruction (SBO).
|
adhesions
|
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Bowel sounds have high-pitched "tinkles" and peristaltic rushes. Diagnosis?
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Bowel obstruction (SBO or LBO)
|
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Leukocytosis and SBO on AXR. What treatment?
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Surgery (ischemia or necrosis)
|
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Metabolic abnormality associated with vomitting.
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Metabolic Alkalosis
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Diagnostic test for SBO and LBO.
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AXR, then likely CT
|
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Stepladder pattern on AXR. Diangosis?
|
SBO
|
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Radio-opaque material at the cecum on AXR. Diagnosis?
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Gallstone illeus
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Pneumobilia (gas in the biliary tree) on AXR. Diagnosis?
|
Gallstone illeus
|
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How to confirm Gallstone illeus if AXR suggests it?
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Small Bowel follow through XR (e.g. Barium)
|
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Presentation of Bowel Obstruction
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cycles of abdominal pain and vomiting
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3rd most common cause of Small Bowel Obstruction (SBO) after hernia and adhesions?
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neoplasm
|
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Treatment for partial SBO (passing flatus).
|
Supportive: NPO, NG suction, IVF, correct electrolyte
|
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Treatment for Complete SBO (Obstipation).
|
surgery
|
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Partial bowel obstruction not resolved after 3 days. Next step in management?
|
surgery
|
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Strangulation of SBO brings risk of this complication up 10 times (compared to non-strangulated SBO).
|
mortality
|
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Abdominal pain characteristic of ileus.
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diffuse, constant, moderate
|
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AXR description of ileus.
|
air in small AND large bowel
|
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Treatment for ileus (3)
|
1) d/c narcotics etc.
2) NPO (parenteral feeds if needed) 3) NG suction as needed to relieve pressure |
|
Most common artery involved in mesenteric ischemia (60% of cases).
|
Superior Mesenteric Artery (SMA)
|
|
2 most common causes of mesenteric ischemia
|
Embolism (e.g AFib or CHF) - 50%
Hypoperfusion (nonocclusive) - 25% |
|
SUDDEN ONSET, severe abdominal pain out of proportion to exam. Diagnosis? What is vital in differential?
|
Bowel Ischemia
|
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H/O series of episodes of abd pain after eating causing weight loss. Now constant pain. Diagnosis?
|
Mesenteric Ischemia
|
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Gold standard imaging test for Mesenteric Ischemia.
|
Mesenteric Angiography
|
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2 treatments for Mesenteric Ischemia (2 As) to start immediately (before surgery)
|
Anticoagulation/thrombolytics and Antibiotics
|
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Mortality rate for mesenteric ischemia?
|
50%
|
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Surgery goals for mesenteric ischemia.
|
emoblectomy and resection of any infarcted bowel; stent if hypoperfusion secondary to atherosclerosis
|
|
Most common cause of lower GI bleeding (LGIB) (60%).
|
diverticulosis
|
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Diet associated with diverticulosis.
|
high fat, low fiber, poor water consumption
|
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Treatment for bleeding diverticulosis.
|
usually self limiting; otherwise: colonoscopy + epineprhine ejection and electrocautery
|
|
LLQ abd. pain and fever. Diagnosis?
|
diverticulitis
|
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Treatment for Diverticulitis?
|
NPO and Antibiotics
|
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Treatment for perforated Diverticulitis.
|
Hartmann's procedure (temporary colostomy)
|
|
Diverticulitis without improvement. Have a low threshold for this test.
|
CT
|
|
Feculent emesis. More likely small or large bowel obstruction?
|
Large
|
|
Bilious emesis. More likely small or large bowel obstruction?
|
Small
|
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Most common cause of Large Bowel Obstruction (LBO) (60%).
|
Cancer
|
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LBO or SBO: which has worse distention?
|
Large
|
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R/O this cause of Bowel Obstruction by physical exam.
|
fecal impaction (digital evacuation)
|
|
Which has more vomiting: LBO or SBO?
|
SBO
|
|
Steptococcus bovis bacteremia. Cause?
|
Colon Cancer
|
|
First colonoscopy age if first degree relative had colon cancer?
|
at 40 or 10 years before age of diagnosis of relative
|
|
3 screening tests that can be used for colon cancer ONLY IF colonoscopy is not available.
|
sigmoidoscopy q5 yrs
FOBT q1 yr DRE q1 yr |
|
One small adenomatous polyp found on colonoscopy and removed. When should next colonoscopy be scheduled?
|
5 years
|
|
2 cm adenomatous polyp found on colonoscopy and removed. When should next colonoscopy be scheduled?
|
3 years
|
|
Five adenomatous polyps found on colonoscopy and removed. When should next colonoscopy be scheduled?
|
1 year
|
|
What number of polyps prompts removal of colon in patient with FAP?
|
100
|
|
Diagnostic test for FAP vs. HNPCC.
|
FAP: colonoscopy and bx
HNPCC: genetic test |
|
Risk of colon cancer in FAP.
|
100% by age 40
|
|
Lifetime risk of colon cancer in HNPCC.
|
80%
|
|
HNPCC caries risk for other cancers. What are the top 3 (besides Colon)?
|
Endometrial
Ovarian Gastric |
|
Fe deficiency in elderly male. Diagnosis?
|
Colorectal cancer until proven otherwise.
|
|
What is the metastatic work-up for Colon Cancer? (3)
|
CXR, LFTs, and CT
|
|
When to use chemo as adjuvant to surgery in treatment of colon cancer?
|
if any lymph node involvement
|
|
Follow-up colon cancer with serial blood tests measuring this level.
|
CEA
|
|
When to schedule next colonoscopy after colon cancer surgery?
|
1 year
|
|
most common site for ischemic colitis.
|
Splenic flexure (watershed area)
|
|
Ischemic colitis is a known complication of this surgery.
|
AAA repair
|
|
Lower abdominal pain and bloody diarrhea; how to confirm a diagnosis of ischemic colitis?
|
colonoscopy
|
|
Treatment of ischemic colitis
|
NPO, IVF, and Antibiotics
|
|
Ischemic colitis patient develops fever and peritoneal signs. Cause?
|
Infarction (needs surgical resection)
|
|
How much should 1 unit PRBC raise the Hct?
|
3 units
|
|
Where is the ligament of trietz? (separation of upper and lower GI tracts)
|
Between Duodenum and Jejunum
|
|
Most common cause of Upper GIB.
|
PUD (50%)
|
|
Top 5 causes of upper GIB.
|
PUD
esophagitis gastritis esophageal varicies mallory-weiss tear |
|
Top 5 causes of lower GIB.
|
Diverticulosis
IBD (UC more than chrons) neoplasm hemorrhoids/fissures AVM |
|
2 tests for UGIB (in order of operation)
|
1) NG lavage
2) EGD |
|
2 options if Octreotide fails to control bleeding varicies.
|
1) EGD w/ ligation
2) TIPS to reduce portal HTN |
|
Medical treatment for bleeding varicies (along with stabilizing).
|
Octreotide
|
|
Classic Barium XR appearance in chrons.
|
areas of poor filling ("string-sign") and deep transverse fissures
|
|
Classic Barium XR appearance in Ulcerative Colitis (UC)
|
loss of haustra ("lead pipe")
|
|
IBD presents with what?
|
alternating constipation and diarrhea
abdominal pain |
|
Most common location of Chron's
|
ileocecal region
|
|
Location limits of Ulcerative Colitis (UC).
|
Rectum to Cecum ("UC is Up to the Cecum")
|
|
Location limits of Chron's.
|
Mouth to Anus
|
|
Thickness of Chron's vs. UC.
|
Chron's: transmural
UC: submucosa |
|
Non-caseating granulomas: Chron's or UC?
|
Chron's
|
|
What is rectal tenesmus? (associated with IBD)
|
Sensation at the anus that evacuation was incomplete
|
|
Fistula: Chron's or UC?
|
Chron's
|
|
What portion of Primary Sclerosing Cholangitis patients have Ulcerative Colitis?
|
70%
|
|
Patient with ulcerative colitis has mild displasia found on colonoscopy bx. Treatment?
|
Total proctocolectomy
|
|
Ulcerative Colitis: continuous or skip-lesions?
|
continuous
|
|
Chron's continous or skip-lesions?
|
skip-lesions
|
|
IBD is more common in these 2 races.
|
Caucasians and Ashkenazi Jews
|
|
Usual age of onset of IBD.
|
15-25 and 50s (bimodal)
|
|
Two 5-ASA agents used to treat IBD.
|
sulfasalazine and mesalamine
|
|
Treatment for IBD refractory to 5-ASA.
|
steroids and immunomodulating agents (azathiprine or infliximab)
|
|
How long after diagnosis of UC must you start yearly colonoscopy with bx?
|
8 years
|
|
Colon cancer risk: UC vs. Chron's
|
UC: markedly increased
Chron's: slightly increased |
|
Classic lesions on colonoscopy: UC and Chron's
|
UC: psuedopolyps
Chron's: cobblestoning |
|
Most common inguinal hernia.
|
indirect
|
|
Which type of hernia goes through the internal inguinal ring?
|
indirect
|
|
Direct inguinal hernia goes through where (in relation to epigastric vessels)?
|
medial to epigastric vessels at Hesselbach's triangle
|
|
What is Hesselbach's Triangle? (direct hernia location)
|
area between inguinal ligament, inferior epigastric artery, and the rectus abdominis
|
|
Why correct hernias?
|
risk of incarceration and strangulation of small bowel
|
|
Indirect inguinal hernia path (in relation to epigastric vessels)?
|
Enters abd wall lateral to and exits medial to epigastric vessels
|
|
Classic risk factors for cholelithiasis.
|
Fat
Female Forty Fertile (pregnant) |
|
Rapid weight loss will do this to the gall bladder.
|
Fill it with stones!
|
|
Sickle cell disease patients often have black gallstones. Why?
|
hemolysis creates pigmented stones
|
|
Brown gallstone means what?
|
infection
|
|
RUQ post-prandial abdominal pain. Diagnosis?
|
biliary colic
|
|
Where does gall-bladder pain classically radiate?
|
Right shoulder
|
|
Symptomatic Cholelithiasis (pain). Tx?
|
cholecystectomy
|
|
Asymptomatic gall-stones (80% of them). Tx?
|
none
|
|
Diagnostic test for cholelithiasis.
|
RUQ U/S
|
|
Treatment for choledocholithiasis?
|
ERCP and then cholecystectomy
|
|
Diet modification for patients with cholelithiasis who refuse surgery.
|
avoid fatty foods
|
|
Cholecystitis symptoms
|
Fever and RUQ abd pain (w/ murphy's sign)
|
|
Trauma and burn victims can present with RUQ pain, and U/S will show no gall-stones. Diagnosis?
|
Acalculus Cholecystitis
|
|
Bili elevated in cholecystitis?
|
no
|
|
Diagnostic lab findings for Choledocholithiasis/Cholangitis.
|
Elevated WBC (varies), Bili, and ALP
|
|
On the Cholecystitis/Choledocholithiasis spectrum, when do you order ERCP? (3)
|
If suspect a stone in duct (any of these):
1) elevated bilirubin 2) elevated ALT or AST 3) U/S shows duct diameter over 8 mm |
|
On the Biliary Colic/Cholecystitis spectrum, when to decide to give Antiobiotics.
|
Anyone with a fever or elevated WBC
|
|
When to order HIDA scan for cholecystitis work-up.
|
if u/s is equivocal
|
|
Why do symptoms vary in choledocholithiasis?
|
extent of bacterial infection varies
|
|
How do gallstones cause pancreatitis?
|
obstruction in the ampulla obstructs the pancreatic duct
|
|
Top 4 causes of Ascending Cholangitis.
|
Choledocholithiasis (most)
PSC Stricture Malignancy |
|
Charcot's triad
|
RUQ pain, jaundice, and fever
|
|
Charcot's pentad
|
RUQ pain
Jaundice Fever Shock AMS |
|
On the Choldocholithiasis/Cholangitis spectrum, when to decide to admit to ICU vs routine ERCP.
|
Clinical decision based on stability.
|
|
Medical treatment for patient's with biliary colic with contraindication to surgery.
|
Urosodeoxycholic Acid
|
|
Define Biliary Colic
|
symptomatic cholelithiasis (pain)
|
|
Define Cholelithiasis
|
Stones in Gallbladder
|
|
Define Cholecystitis
|
Inflammation of Gallbladder wall (caused by transient stone obstruction)
|
|
Define Choledocholithiasis
|
Gallstone in the bile duct
|
|
If choledocholithiasis becomes symptomatic, what are the symptoms caused by?
|
ascending bacterial infection and/or cholecystitis
|
|
Define Cholangitis
|
Inflammation of the Bile Duct
|
|
Define Ascending Cholangitis
|
Inflammation of the Bile Duct caused by ascending bacterial infection (usually caused by choledocholithiasis)
|
|
1st line treatment for Ascending Cholangitis.
|
Emergent bile duct decompression with ERCP with sphincterotomy
|
|
Treatment of gallstone illeus
|
laparotomy and stone extraction or manipulation into colon
|
|
PSC vs. PBC: men or women
|
PSC: mostly young men
PBC: mostly middle aged women (remember B for Bitches) |
|
PSC vs. PBC: which one associated with Ulcerative Colitis?
|
PSSSSC is associated with ulSSSSerative colitiSSSS
|
|
2 other options if ERCP fails to drain Bile Duct in Cholangitis.
|
T-tube placement or Transhepatic drainage
|
|
Extraintestinal manifestations of IBD: dermatology (2).
|
Eythema Nodosum
Pyoderma Gangrenosum |
|
Extraintestinal manifestations of IBD: eye.
|
episcleritis/uveitis
|
|
Extraintestinal manifestations of IBD: most common.
|
arthritis: both axial (e.g. anklyosing spondylitis) and peripheral
|
|
Feared complication from PSC.
|
Cholangiocarcinoma
|
|
There is an "M" diagnostic test for both PSC and PBC. What is each?
|
PSSSSC: MRSSSSeeP (MRCP)
PBC: anti-Mitochondrial antibody (AMA) |
|
PBC and PSC both present this way.
|
Progressive jaundice and pruritus.
|
|
Idiopathic inflammation, fibrosis, and strictures of Intra AND Extrahepatic bile ducts. Diagnosis?
|
PSC
|
|
Why do more PSC patients get liver transplants than PBC patients?
|
Urosodeoxycholic Acid controls PBC, but fails to control PSC
|
|
Eventually PSC patients will need this treatment.
|
Liver Transplant
|
|
Autoimmune destruction of Intrahepatic ducts. (Intra only). Diagnosis?
|
PBC
|
|
PBC has malabsorption of these vitamins.
|
Fat soluble (ADEK)
|
|
Initial medication for both PBC and PSC.
|
Urosodeoxycholic Acid
|
|
Which pattern on LFT panel indicates Hepatocellular injury?
|
AST and ALT elevation
|
|
What LFT panel pattern indicates Cholestasis?
|
elevated ALP and Bili
|
|
Isolated ALP elevation and Bone Pain. Diagnosis?
|
Malignant bone disease
|
|
Isolated ALP elevation and Fatigue. Diagnosis.
|
Multiple Myeloma
|
|
Unknown reason for ALP elevation. What test will confirm a liver origin?
|
positive GGT
|
|
What tests will confirm hemolysis as a source of unconjugated hyperbilirubinemia?
|
LDH (high) and Haptoglobin (low)
|
|
Biliary duct dilation: PBC or PSC?
|
PSC (PBC is INTRAhepatic only)
|
|
Gilbert's, Dubin-Johnson, Rotor's, Crigler-Najjar: direct or indirect hyperbilirubinemia?
|
Gilbert's: indirect (defective conjugation)
Crigler-Najjar: inderect (defective conjugation) Dubin-Johnson: direct (defective excretion) Rotor's: direct (defective excretion) |
|
Intrahepatic Cholestasis (no bile duct dilation): 4 causes
|
Meds
Post-op Sepsis PBC |
|
Billiary Obstruction Cholestasis (bile duct dilation)
|
Choledocholithiasis
Pancreatic Cancer Cholangiocarcinoma PSC (stricture) |
|
Isolated ALP elevation. What to do?
|
1st repeat LFTs while fasting; if still high, get a GGT
|
|
Hepatitis viruses transmitted fecal-orally.
|
HAV and HEV
|
|
Isolated ALP elevation and NO SX. Negative GGT (non-liver source). What is the most likely source?
|
Paget's Disease of the Bone (Osteitis Deformans)
|
|
2 general categories of causes of acute hepatitis.
|
Virus and Drug
|
|
4 Hereditary Diseases which can cause elevated LFTs.
|
hemochromatosis
A1 AntiTrypsinogen Defic. Wilson's Disease Celiac Sprue |
|
6 Categories of Hepatocellular Injury Differential.
|
Viral
Hereditary Autoimmune NAFLD Drugs/toxins Vascular |
|
Name 4 other viruses (besides Hepatitis viriuses) that can cause elevated LFTs.
|
CMV
EBV HSV VZV |
|
Which Hepatitis Virus requires presence of HBV to propagate?
|
HDV
|
|
How are HBV and HCV transmitted?
|
bodily fluids
|
|
What percent of HCV patients will develp chronic hepatitis?
|
80% (remember hCv is Chronic)
|
|
How to diagnose Wilson's Disease?
|
Ceruloplasmin level
|
|
2 tests to order to diagnose hemochromatosis?
|
Fe studies followed by genetic testing
|
|
Exam in actue hepatitis.
|
Jaundice and Hepatomegaly tenderness (also look for splenomegaly and lymphadenopathy)
|
|
LFT panel pattern with acute Hepatitis.
|
Dramatically elevated ALT, AST; elevated bili and ALP too
|
|
Tests when suspecting Autoimmune Hepatitis (3).
|
ANA
AMA (for PBC) SMA (anti-smooth muscle antibody) |
|
Treatment of Autoimmune Hepatitis.
|
Immunosuppression: e.g. prednisone +/- azathioprine
|
|
Treatment of severe Alcoholic Hepatitis (besides discontinuing Alcohol).
|
Steroids
|
|
Acute Hepatitis B Treatment.
|
Supportive
|
|
Chronic Hepatitis B Treatment
|
IFNalpha, lamivudine (3TC), or adefovir
|
|
Chronic Hepatitis C Treatment
|
peginterferon and ribavirin
|
|
Treatment for end-stage liver failure.
|
Liver Transplant
|
|
Screen Chronic Hepatitis patients with AFP and/or U/S for Hepatocellular Carcinoma how often?
|
q6 months
|
|
IgM HAVAb is used for?
|
detect active Hep A
|
|
HBsAg indicates what?
|
Indicates carrier state (high in acute, lower in chronic)
|
|
What percent of adult aquired Hep B becomes Chronic Hepatitis?
|
less than 5%
|
|
What percent of perinatal aquired Hep B becomes Chronic Hepatitis?
|
more than 90%
|
|
HBcAb and HBsAb are positive. Indicates what?
|
Past HBV infection and now immune.
|
|
HBsAb indicates what?
|
Antibody to HBsAg (Immunity to HBV)
|
|
IgM HBcAg indicates what?
|
Recent/Resolving infection
|
|
HBeAg indicates what?
|
high transmissibility (BEware of hBEag)
|
|
HBeAb indicates what?
|
low transmissibility
|
|
In early Acute Hep B infection, what is the only marker that is positive?
|
HBsAg
|
|
Active Acute Hep B infection, What 2 markers are positive?
|
HBsAg and HBcAb (IgG)
|
|
HBcAg (IgG) indicates what?
|
Active infection
|
|
In a person vaccinated against Hep B, what is the only positive marker?
|
HBsAb
|
|
In a person with chronic Hep B, what 2 markers will be positive?
|
HBsAg and HBcAb
|
|
Is Alcohol the only thing that causes Cirrhosis?
|
no: any chronic hepatitis can lead to cirrhosis
|
|
Fibrosis and nodular regeneration due to hepatocellular injury. This is the definition of what?
|
Cirrhosis
|
|
3 locations of anastomoses which enlarge with portal hypertension (e.g. from cirrhosis).
|
Esophgus (Gut)
Hemorrhoids (But) Paraumbilical (Caput madusae) |
|
Asterixis and Altered Mental Status. Diagnosis?
|
Hepatic Encephalopathy
|
|
Decreased protein production in liver failure results in these 2 abnormal labs.
|
Albumin
Coags (PT/PTT) |
|
Hypersplenism accompanying liver failure may cause these 2 abnormalities in the blood.
|
Anemia and Thrombocytopenia
|
|
Imaging study of choice for liver disease.
|
U/S with doppler
|
|
Test to confirm Cirrhosis.
|
Liver Biopsy
|
|
Work up for Ascites (2 tests)
|
SAAG (Serum Albumin:Ascites Albumin Gradient)
AFTP (Ascites Fluid Total Protein) |
|
SAAG (Serum Albumin:Ascites Albumin Gradient) is less than 1.1; what are 3 things on differential.
|
Nephtrotic Syndrome
TB Malignancy (e.g. ovarian CA) |
|
AFTP (Ascites Fluid Total Protein) is under 2.5; what is the most likely diagnosis?
|
Cirrhosis
|
|
Portal HTN related Ascites has what SAAG?
|
over 1.1
|
|
Treatment steps for Ascites (4 steps: name them in the proper order).
|
1) sodium and water restrict
2) add Spiranolactone 3) add Furesemide 4) serial paracentesis |
|
AFTP (Ascites Fluid Total Protein) is over 2.5; what is the most likely diagnosis?
|
Right Heart Failure
|
|
Cirrhotic patient gets fever and AMS. Diagnosis?
|
Spontaneous Bacterial Peritonitis (SBP)
|
|
How to diagnosis SBP (criteria?)
|
check (ascites): infection if:
over 250 PMNs or over 500 WBCs per mL |
|
Treatment of SBP
|
3rd gen Cephalosporin (e.g. Cefotaxime)
|
|
Supplement to give patient who is recovering from SBP (and when to give it).
|
Protein to be given x1 at diagnosis and x1 on day 3
|
|
Patient has recovered from SBP for the second time. What prophylactic med to start?
|
Bactrim qDay
|
|
If SAAG is over 1.1, how to differentiate between cirrhosis from cardiac.
|
AFTP (Ascites Fluid Total Protein)
|
|
What causes hepatic encephalopathy
|
build of ammonia from failed liver metabolism
|
|
Treatment of Hepatic Encephalopathy (3)
|
Protein restriction
Laculose Rifaximin |
|
2 "Major" (positive) criteria in diagnosis of Hepatorenal syndrome
|
Rapid renal failure that 1) does not respond to IVF in patients with
2) Portal Hytertension 2/2 liver disease |
|
In what group should you specifically watch for Hepatorenal Syndrome?
|
Alcoholic cirrhosis patients
|
|
What are the 2 most common triggers of Hepatorenal Syndrome in Cirrhotic patients?
|
infection (e.g. SBP) and UGIB
|
|
Treatment for Hepatorenal Syndrome
|
Dialysis and likely Liver Transplant
|
|
Painless jaundice. Diagnosis?
|
Obstruction of the Bile Duct by advance cancer in the Pancreatic Head
|
|
2 largest risk factors for Hepatocellular Carcinoma (in the U.S.)?
|
Cirrhosis (i.e. Alcoholism) and HCV
|
|
Hepatic masses in liver on U/S. What is the most common cancer?
|
Colon Cancer Mets (far more common than Primary)
|
|
What protein is measured for Hepatocellular Carcinoma?
|
Alpha Fetoprotein (AFP)
|
|
Cirrhotic patient with 5 month h/o worsening liver function and new weakness and cachexia. Diagnosis?
|
Hepatocellular Carcinoma
|
|
Screening AFP in chronic hepatitis patient is elevated. What imaging to order?
|
CT
|
|
Process of work-up in Hepatocellular Carcinoma (Name 3 steps in the correct order).
|
1) AFP and/or U/S
2) CT 3) Biopsy |
|
Treatment of Hepatocellular Carcinoma.
|
Resection curative if early tx; poor prognosis if metastatic (no tx option)
|
|
Why might one use chemotherapy and radiation in Hepatocellular Carcinoma if they are generally not effective?
|
Reduce large tumors before surgery (neoadjuvant therapy)
|
|
Lab to monitor for recurrance of Hepatocellular Carcinoma.
|
AFP
|
|
How common is hemochromatosis in U.S.
|
1 in 300
|
|
Pathophysiology of hemachromotosis in the liver (and other organs)
|
hemosiderin accumulation
|
|
Genetic inheritance pattern in Hemachromotosis.
|
Autosomal Recessive
|
|
Age of presentation in Hemachromotosis
|
40-50 (rarely before)
|
|
What is the most common cause of pain in Hemachromotosis?
|
Arthropathy of MCP joints
|
|
What heart disease does hemochromatosis cause?
|
Restrictive Cardiomyopathy (and Heart Failure)
|
|
Diffuse Bronze skin pigmentation. Diagnosis?
|
Hemochromotosis
|
|
What do Iron studies look like in Hemochromotosis?
|
Increased: Fe (TSI), Fe/TIBC (TSat), Ferritin
Decreased: Transferrin (TIBC) |
|
What test is used to estimate Transferrin level?
|
Total Iron Binding Capacity (TIBC)
|
|
What TSat level to consider ordering for Hemochromotosis mutation panel?
|
Over 0.45
|
|
Diabetes, Hypogonadism, Arthritis, and Heart Failure. Diagnosis?
|
Hemochromotosis
|
|
Tretment of Hemochromotosis.
|
Phlebotomy with frequency titrated until Tsat (Fe/TIBC) under 30% and Ferritin is under 50
|
|
Cancer associated with Hemochromotosis (Cirrhosis)?
|
Hepatocellular Carcinoma
|
|
Symptoms of Wilson's disease are caused by what?
|
deposition of copper in liver (cirrhosis) and brain (neuro/psych); unknown hemolysis mechanism
|
|
Age of presentation of Wilson's Disease?
|
Teens to Twenties
|
|
Name and describe the eye finding in Wilson's Disease?
|
Kayser-Fleischer rings (green ring in the base of the cornea which shows up at outer edge of the iris)
|
|
Treatment for Wilson's Disease: increase urinary excretion
|
Penicillamine (with Vit B6)
|
|
Treatment for Wilson's Disease: decrease Copper absorption and increase fecal excretion.
|
Zinc
|
|
Treatment for Wilson's Disease: foods to avoid.
|
Liver, Legumes, Seafood (especially oysters)
|
|
What deficiency causes Wilson's Disease?
|
Ceruloplasmin
|
|
Why is MRI a common way for Wilson's Disease to be first found?
|
Neuro signs in such a young patient (teens/twenties)
|
|
2 most common neuro complaints of wilson's disease.
|
loss of coordination and tremor
|
|
Abrupt severe epigastric pain radiating to the back. Diagnosis?
|
Pancreatitis
|
|
Why get a CT scan in pancreatitis if the diagnosis can be made clinically?
|
to check for pseudocysts, abscesses, or necrosis
|
|
Why get an U/S in pancreatitis?
|
identify any gallstones
|
|
Treatment for acute pancreatitis?
|
NPO, IVF, and opiods
|
|
When to give Antibiotics in pancreatitis?
|
if necrotizing pancreatitis develops
|
|
Flank discoloration with pancreatitis. Name the "sign"
|
Grey Turner's sign
|
|
Periumbilical discoloration with pancreatitis. Name the sign.
|
Cullen's sign
|
|
top 2 causes of acute pancreatitis (40% of cases each)
|
alcohol and gallstones
|
|
Next 3 most common causes of acute pancreatitis to consider in a non-alcoholic with no gallstones (2-4% of cases each)
|
ERCP
Abdominal Trauma Medication |
|
Ranson's Criteria on Admission (GALAW mnemonic)
|
Glucose up
Age over 55 LDH up AST up WBC up |
|
Ranson's Criteria at 48 hours (CHOBBS mnemonic)
|
Calcium decreased
Hct dropping paO2 down Base excess BUN increasing Sequestered fluid |
|
How to calculate mortality risk in acute pancreatitis?
|
Ranson's Criteria
|
|
Suspect pancreatic cancer. Imaging to order?
|
CT
|
|
Why is pancreatic cancer such a death sentence?
|
presentation is usually with advanced/metastatic disease
|
|
10% of patients with pancreatic cancer have isolated pancreatic head tumors and can undergo this procedure.
|
Whipple procedure (pancreaticoduodenectomy)
|
|
Palliative chemo options for pancreatic cancer.
|
5-Fu and gemcitabine
|
|
Remember to take Vit B6 if taking either of these 2 medications.
|
Penicillamine or Isoniazide (INH)
|
|
Adolescents with extrapyramidal or cerebellar motor disorders, atypical psychiatric disease, unexplained hemolysis, and elevated transaminases. Most likely diagnosis?
|
Wilson's Disease
|