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110 Cards in this Set
- Front
- Back
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In a PCN allergic pt what would be the initial treatment for H. pylori?
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Triple therapy:
1. PPI 2. Clarithromycin 3. Metronidazole |
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If a pt fails initial triple therapy for H. pylori what treatment should be given next?
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Quadruple therapy:
Bismuth, Metronidazole, Tetracycline, PPI |
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What antibiotic is H. pylori naturally resistant to?
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Trimethoprim
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In a PCN allergic pt what would be the initial treatment for H. pylori?
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Triple therapy:
1. PPI 2. Clarithromycin 3. Metronidazole |
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If a pt fails initial triple therapy for H. pylori what treatment should be given next?
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Quadruple therapy:
Bismuth, Metronidazole, Tetracycline, PPI |
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What antibiotic is H. pylori naturally resistant to?
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Trimethoprim
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What type of liver inury can TMP/Sx cause? Dx? Tx?
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1. Cholestatic pattern
2. Diagnosis of exclusion; need to eliminate alternate causes 3. Observation |
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What type of liver injury can phenytoin cause?
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Mixed liver disease
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What type of liver injury can acetaminophen cause?
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Elevation in transaminases
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What should be the initial treatment for mild ulcerative colitis ?
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1. 5-ASA
2. |
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When should corticosteroids be used in ulcerative colitis?
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For acute flares and not for maintenance therapy
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What are steroid sparing agents in ulcerative colitis?
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Immunomodulators:
6-Mercaptopurine Azathioprine - Either should be started with steroids and usually take effect in about three months |
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When should pts with ulcerative colitis or Crohn's be screened for cancer and how often?
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1. They should be screened 8 years after diagnosis and should be repeated every 1-2 years
2. Biopsies are performed in a four quadrant fashion throughout the colon 3. Note treatment with mesalamine does not decrease cancer risk |
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1. What findings make one suspicious for a gastrinoma?
2. What is the first step to diagnosis? 3. What is the most sensitive test in detecting a gastrinoma? |
1. Presence of multiple gastric ulcers with a negative H. pylori and no history of NSAID use
2. Measure gastrin level followed by CT Abdomen 3. Somatostatin receptor scintigraphy |
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What is the next diagnostic step in a pt with a high probability of GERD who does not have alarm symptoms and continues to ahve symptoms?
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pH esophageal monitoring
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What is the treatment of NSAID induced small bowel ulcer?
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Discontinuation of NSAIDs and observation
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What is the best next step in evaluating a pt < 55 y/o with dyspepsia symptoms and no alarm signs?
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Test and Treat Strategy:
Test for H. pylori via stool test If positive treat If treatment does not resolve symptoms proceed to EGD |
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What are the clinical signs for autoimmune disease in a pt?
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1. Hx or family hx fo autoimmune disease
2. Non-cholestatic liver injury pattern 3. ANA, anti-smooth muscle Ab, Anti-liver/kidney microsome type 1 are positive; only positive in 25% of pts and are not prognostic 3. Typically females |
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What are the clinical signs of primary biliary cirrhosis?
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1. Cholestatic liver injury
2. Females 40-60 y/o 3. Triad: Cholestatic picture, antimitochondrial Ab +, and consistent histological findings |
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What are the clinical signs of primary sclerosing cholangitis?
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1. Cholestatic liver disease
2. Destruction of biliary ducts |
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When should a pt with IBD be placed on empiric C diff antibiotics?
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1. Recent hx of antibiotic use with increase in stools
2. Tachycardia, hypotension, and leukocytosis; Febrile - Start either PO metronidazole or vancomycin x 10 days |
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What is the preferred method of eating in a patient with acute pancreatitis?
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Enteral feeding - if feeding tube should be place passed Ligmanet of Treitz
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How is slow transit constipation diagnosed?
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Rome III criteria for STC (need 2/3 for at least 3 months):
1. Straining for > 25% of bowel movements 2. Lumpy or hard stools for > 25% of defecations 3. Sensation of anorectal obstruction for > 25% of defecations 4. Manual maneuvers to facilitate defecations for > 25% of BMs 5. < 3 BMs per week |
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What is the first step in management of variceal hemorrhage?
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1. Fluid resuscitation
2. Octreotride - decreases portal venous flow 3. Antibiotics |
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What is a common cause of MALT lymphoma?
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H. pylori infection
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What are the common features of achalasia on manometry?
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1. Lack of relaxation of LES with swallowing
2. Elevated LES pressure 3. Absent or diminished peristalsis of esophageal body |
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How is the diagnosis of spontaneous bacterial peritonitis made?
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Must have absolute PMN count of ascitic fluid be > 250/mL
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If a patient with Crohn's disease has become azathiopurine resistant what is the next step in management?
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Taper the azathiopurine then start on immunomodulator like inflixamab; do not do both azathiopurine and infliximab as increase risk for T cell lymphoma
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How is the diagosis of esophageal spasms made on manometry?
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Greater than 20% of swallows have simultaneous contractions in the distal esophagus
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What is the first step in treament for DES?
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Anti-reflux medication
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Patient with hx of bariatric surgery presents with abdominal pain, boating, diarrhea, and malabsorption symptoms. What is a likely diagnosis?
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Small Bowel Bacterial overgrowth
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What are key lab findings in small intestine bacterial overgrowth?
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1. Macrocyttic Anemia
2. Decreased B12 level 3. Elevated folate (bacteria in gut synthesize folate) |
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What are the ways to diagnose small bowel overgrowth?
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1. Breath testing
2. Small bowel cultures |
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What are the type of microscopic colitis?
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1. Lymphocytic colitis
2. Collagenous colitis |
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What are the indicators for pancreatic necrosis in pancreatitis? Treatment?
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1. If a patient has not been improving after 5 days of treatment for pancreatitis; CT also will identify pancreatic necrosis, but ERCP will not
2. Imipenem should be started as prophylactic therapy |
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When and what is the purpose fo calculating the discriminant function?
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1. Should be calculated in patient with acute alcoholic hepatitis (AST, ALT usually in100s)
2. If > 32 means > 50 mortality in next 30 days ; identifies patient who would benefit form corticosteroids |
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What is the initial treatment of diffuse esophageal spasm?
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1. PPI as DES is commonly related to reflux
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What is the treatment of pancreatic insufficiency?
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Enzyme replacement therapy
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What are the findings of Achalasia on manometry?
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1. Elevated lower esophageal sphincter pressure
2. Failure of lower esophageal sphincter to relax with swallowing 3. Lack of peristalsis |
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What is the treatment of Achalasia?
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1. Surgical myomectomy
2. Pneumatic dilation 3. Botulinum toxin injection for nonsurgical candidates |
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If a patient has gastric erosion/ulceration from NSAID use for RA what therapy should be initiated?
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Start PPI without stopping NSAIDs
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What is the management of a liver abscess?
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1. Percutaneous drainage
2. Empiric Antibitoics followed by antibiotics for 4-6 weeks - Wedge resection of the liver does not need to be done |
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What is the treatment of gallstone pancreatitis with biliary obstruction?
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ERCP
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What is the diagnostic test to identify mesenteric ischemia?
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CT- arteriorography
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What should pain with swallowng make you think of?
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Pill esophagitis versus infection (candida esophagitis)
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Pt has intermittent dysphagia for solids and liquids especially cold liquids with chest pain. Barium swallow shows corkscrew appearance. Dx? Tx?
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1. Diffuse esophageal spasm
2. Trial PPI/ Ant-spasm agents/Anti-anxiety/CCBs = nothing works well |
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Intermittent solid food dysphagia with steak or chicken. Pt regurgitates for relief. Dx? Tx?
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1. Schatzki ring
2. Dialtion with PPI after |
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What is the most common cause of esophageal strictures? Tx?
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1. Reflux
2. Dilation |
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How do you calculate stool osmolality gap?
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2 x (Na + K) - measured stool osm
If > 50 then osmotic diarrhea |
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What is the treatment of H. pylori?
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Triple: Clarithromycin, Amoxicillin, and omeprazole
Triple PCN allergy: Clarithromycin, Metronidazole, Omeprazole Quad therapy: Bismuth salicylate, Metronidazole, Tetracycline, Omeprazole |
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What may lead to false tests for H. Pylori?
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PPI use ; stool test may still be accurate
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What disease distribution can sulfasalazine enemas and suppositories be used?
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Proctitis - Suppository
Soigmoiditis - Enema |
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What autoimmune disease can lead to small bowel bacterial overgrowth?
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Scleroderma
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Does bacterial overgrowth create and osmotic or secretory diarrhea?
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Osmotic
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What is the treatment of bacterial overgowth?
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1. Tertracycline
or 2. Amoxi-Clavulanate or 3. Rifaxamin |
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How is carcinoid diagnosed?
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Urine 5-HIAA
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What is collagenous colitis? Associated with? Dx?
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Chronic watery diarrhea
Associated with NSAIDs, autoimmune diseases Need colonoscopy or sigmoidoscopy to make diagnosis See collagen in biopsy |
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Most colon cancers arise from what type of polyp?
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Adenomas
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What is the proper repeat surveillance time after finding a polyp?
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If no polyp or hyperplastic - repeat in 10 years
If one or two small adenomas < 1 cm then repeat in 5 years If 3-10 adneomas, any single adenoma > 10mm, adenoma with villous features, or high grade dysplasia repeat in 3 years |
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What is the inheritance pattern of FAP?
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Autosomal dominant
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If a person has thundreds of colonic polyps, osteomas, and soft tissue tumors. What is the diagnosis?
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Gardner syndrome
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What is the Tx of FAP?
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Colectomy
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What screening do patients with FAPneed?
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Upper EGD for duodenal polyps (gastric polyps non-concerning)
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What tumor marker is monitored in the treatment of colon cancer?
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CEA
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What are the stages of colon CA? Tx
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TNM stage 1, Duke A - Limited to mucosa and submucosa; Resection + follow up
TNM stage 2, Duke B - Penetrated muscularis but has not entered LNs; Chemo if locally advanced TNM stage 3, Duke C - Extended to lymph nodes; FOLFOX; 5FU + lucovorin +oxiplatin TNM stage 4, Duke D - Distant metastases; palliative Radition helpful for rectal lesions prior to surgery |
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What bacteria necessitate a colonoscopy for colon ca screening?
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Strep bovis, Clostridium septicum
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What is the antibiotic regimen for acute diverticulitis?
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Aminoglycoside + metronidazole or 2nd/3rd gen cephalosporin
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If a patient presents with recurrent pancreatitis and sludge on US what is the next step?
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Cholecystectomy
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What is the indication for antibiotics in pancreatitis? Which antbiotic
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If necrosis on CT; imipipenem
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What are the types of microscopic colitis?
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Microscopic colitis
1. Collagenous colitis 2. Lymphocytic colitis Both present with watery diarrhea |
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How do you calculate the discrimnant function?
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(4.6 × [prothrombin time − control prothrombin time]) + serum bilirubin)
A discriminant function score of greater than 32 identifies patients with a 50% mortality rate within 30 days and has been used to identify patients who have a survival benefit from corticosteroid therapy. |
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What is the management of a hepatic abscess?
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Start IV antibiotics and have it percutaneously drained
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What tumor maker is associated with pancreatic cancer?
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CA 19-9
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What is an indication for a HIDA scan?
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Acute cystic duct obstruction
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Who develops acalculous cholecystitis? Dx? Tx?
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1. Usually very sick hospitalized patients
2. US shows thickened gallbladder without stones 3. Cholecystectomy |
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What are some complications post cholecystectomy?
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Bile duct leak immediately after procedure
Months to ears later retained gallbladder stones |
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What disease is associated with antimitochondrial antibody?
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primary biliary cirrhosis
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How is PBC diagnosed? Tx?
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Need biopsy; See nonsupparative destruction of bile ducts
Tx: Cholestyramine for iching, calcium, vit D, restrict dietary fat. medium chain triglycerides due to malabsorption; tx with ursodiol; needs liver transplant |
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What disorder is anti smooth muscle antibody associated with?
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Autoimmune hepatitis
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What other GI disorder is associated with PSC?
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IBD - UC or Crohn's
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What immunologial marker is positive in PSC?
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pANCA
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How is PSC diagnosed? Complications? Tx?
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Dx: Elevated ALP, AST, ALT with normal bili; MRCP/ERCP show multiple strictures of intra/extra hepatic ducts
Complications: Liver failure, cholnagiocarcinoma Tx: Liver transplant, ursodeoxycholic acid for pruritis; need annual screening at time of diagnosis |
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What hep B treatment has highest risk of developing resistance?
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Lamivudine
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What are the indications for hepatitis B treatment?
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1. HBeAg +
2. HBeAg - but HBV DNA + 3. Compensated cirrhosis with HBV DNA > 2000 |
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If a health care worker develops a needle stick with a Hep C pt when is prophylactic tx indicateD?
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No prophylaxis
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What skin manifestation is associated with hepatitis C?
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Poprhyrea cutanea tarda
Skin rashes |
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What is the initial treatment of Hep c?
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Interferon + ribivarin
(indications include biopsy proven liver fibrosis, abnormal LFTs) |
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Which Hep C genotype is most prevalent in US and most resistant to treatment?
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Genotype 1
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What is a complication of ribavarin?
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hemolytic anemia
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What are the milan criteria?
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1 lesion less than 5 cm
2-3 lesions less than 3 cm each NO macrovascular invasion No lymphatic spread |
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How is hepatorenal syndrome diagnosed? Tx?
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Urine sodium < 10; Midodrine and Octreotide
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What is the treatment of SBP?
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Cefotaxime + IV albumin
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What is Gilbert's syndrome? Inheritance pattern>
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Stress induced unconjugated hyperbli
Autosomal Dominant |
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How is wilson disease diagnosed?
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Low ceruloplasmin with an elevated urinary copper and high copper content in liver biopsy
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On EGD see multiple esophageal rings with raised white specks, longitudinal furrows, and friable esophageal mucosa. Histologic examination of the mucosa shows intense inflammation of the lamina propria with more than 15 eosinophils per high-power field. Setting of dysphagia. DX? Tx?
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Eosinophillic esophagitis
Liquid oral corticosteroid |
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PT s/p bariatric surgery presents with diffuse aches and elevated ALP. Dx?
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Vitamin D deficiency
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CT scan of the abdomen shows a well-circumscribed lesion in the right lobe of the liver with an enhancing central scar; the rest of the liver appears to be normal, and there is no intra- or extrahepatic duct dilatation. Dx?
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Focal Nodular hyperplasia; can observe; not estrogen sensitive so do not need to stop OCPs
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what screening test is indicated in patient who have new found cirrhosis?
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EGD for variceal screening
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What are the Amsterdam II clinical criteria for hereditary nonpolyposis colorectal cancer (HNPCC)?
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3-2-1 rule: three relatives with an HNPCC-associated cancer, two generations affected, one person diagnosed before age 50 years. She should therefore be considered to be at risk for cancers associated with the disorder despite the negative genetic tests.
Recommendations included colonoscopy every 1 to 2 years from age 20 to 25 years and surveillance for gynecologic malignancy every 1 to 2 years from age 30 years. |
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If medical therapy does not improve hepatorenal syndrome what is the next best step?
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Liver transplantation - replacing the liver resolves the kidney issues
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What is the treatment of primary biliary cirrhosis?
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ursodeoxycholic acid
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What further surveillance and testing do gastric polyps require?
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None
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Are simple cysts reactive to estrogen? Should you stop OCPs if a pt has a simple cyst?
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No/No
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If a primary relative has a colon adenoma or cancer when should the patient be screened?
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At age 40 or 10 years younger than when their relative was diagnosed; whichever was younger
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If a patient has gastroparesis symptoms but has heartburn as well what is the next step?
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EGD; need to rule out obstructing ulcer then can proceed to gastric scintigraphy
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Third trimester of pregnancy and is associated with pruritus and mild elevation of the bilirubin level with or without a mild elevation of the aminotransferase levels. Absence of other potentially dangerous pregnancy-related liver diseases. Dx? Tx?
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Cholestasis of pregnancy
ursodeoxycholic acid |
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A biopsy of the abnormal esophageal mucosa shows intestinal metaplasia with goblet cells. The patient is asymptomatic, and her only medication is omeprazole, 40 mg/d.
Which of the following is the most appropriate management for this patient? |
Endoscopic surveillance
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What does a biopsy of a hepatic adenoma show?
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Sheets of hepatocytes; peripherally enhancing leisions on CT
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What is the study of choice for oropharyngeal dysphagia (trouble initiating a swallow) ?
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Videofluroscopy
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What is the primary evaluation modality for esophageal dyspepsia?
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EGD
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