Gp-Mksap-Gi-05

Front 1

=== GALLBLADDER ===

Back 1

=== GALLBLADDER ===

Front 2

Cholecystitis dx?

Back 2

RUQ Sono, if indeterminant do HIDA

Front 3

Prophylactic cholecystectomy should be considered in ?

Back 3

patients with gallbladder polyps larger than 1 cm, gallstones larger than 3 cm, or porcelain gallbladder to prevent gallbladder cancer, some Indians

Front 4

Preferred therapeutic method for relieving obstruction due to choledocholithiasis, with or without acute cholangitis?

Back 4

ERCP.
Cholecystectomy in 6 mo (or sphincterotomy if poor candidate)

Front 5

Acalculus cholecystitis

Back 5

Acute a calculus cholecystitis is gallbladder inflammation in the absence of obstructive stones.

Predisposing factors: hospitalization for critical illness, burns, advanced age, aids, infection with salmonella or CMV, polyarthritis nodosa, SLE, atherosclerotic vascular disease

SX:
–Unexplained fever
–Hyperamylasemia

Pearls:
–Approximately 50% of these high–risk patients will develop cholangitis, empyema, gangrene, gallbladder perforation during their hospitalization

RX:
–IV anabiotic's
–Cholecystectomy but likely contraindicated in critically ill; therefore decompression with image guided percutaneous tube placement.

Front 6

Cholangitis: appearance, cause, tx?

Back 6

– fever, jaundice, and pain in the RUQ (Charcot triad).
– cholelithiasis, elevated AST/ALT, hyperbilirubinemia.
– US with dilated CBD
MRCP is a more sensitive study than ultrasonography.
– E. coli, Klebsiella species, Pseudomonas species, and enterococci
– tx with emperic abx and urgent decompression with ERCP

Front 7

GB cancer, risk factors?

Back 7

Risk factors for gallbladder cancer are age > 50, female sex, gallstones, obesity, gallbladder polyps larger than 1 cm, stones > 3 cm, chronic infection with Salmonella typhi, and porcelain gallbladder

Front 8

GB cancer, general treatment?

Back 8

- Open chole if confined
Radical chole if spread to adjacent organs
- else, palliative tx (no role of chemo or RXT)

Front 9

Cholangiocarcinoma is? Risk factors?

Back 9

– cancer derived from the biliary tree exclusive of the gallbladder or the ampulla.
– Risk factors are primary sclerosing cholangitis, biliary atresia, liver flukes, and biliary cysts

Front 10

Klatskin tumor?

Back 10

Cholangiocarcinoma of the hilum
– suspect when bile duct dilated and obstructing lesion
– poor survival even with resection

Front 11

Ampullary adenocarcinoma?

Back 11

– rare,most often in hereditary polyposis syndromes such as FAP or Peutz–Jeghers
– pts should undergo regular surveillance EGD
– most are are resectable (whipple) , good px

Front 12

Biliary Cysts, presentation, management?

Back 12

- chronic, intermittent abdominal pain and recurrent bouts of cholangitis or jaundice

- ERCP shows cystic dilatation of the bile ducts and the absence of obstruction

- do Operative resection -> reduces risks of malignancy

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Front 16

=== GI BLEED ===

Back 16

=== GI BLEED ==

Front 17

Sources melena

Back 17

–Esophagus
–Stomach
–Small intestine
–Proximal colon

Front 18

Hematochezia

Back 18

Red or maroon colored blood per rectum.

Is most commonly caused by lower G.I. bleeding but when seen in upper GIB typical means heavy bleeding.

Front 19

Dieulafoy lesions

Back 19

They are submucosal arterioles that it intermittently protrude through the mucosa and can cause hemorrhage

Front 20

Common causes of upper G.I. bleed

Back 20

–PUD 38%
–Esophageal varices 16%
–Esophagitis 13%
–Malignancy 7%
–Mallory–Weiss tear 4%
–Dieulafoy lesions 2%

Front 21

evaluation of UGIB?

Back 21

In patients with upper gastrointestinal bleeding, upper endoscopy should be performed after hemodynamic stabilization but within 24 hours of presentation (sooner if variceal bleeding is suspected).

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Front 23

Alarm features for upper endoscopy in Gerd:

Back 23

Onset after age 50, anemia, dysphasia, odynophagia, vomiting, weight loss, family history of upper G.I. cancer, personal history of PUD.

Front 24

guidelines for doing endoscopy on anticoagulation?

Back 24

– supratherapeutic INR should receive fresh frozen plasma
– risk of continued bleeding on warfarin therapy must be weighed against risk of stopping anticoagulation
– endoscopy should not be delayed for anticoag reversal unless INR >3

Front 25

When should you reverse anticoagulation in upper G.I. bleed?

Back 25

Inpatients with variceal bleeds prior to upper endoscopy.

Patients with none variceal bleeds of the upper G.I. track should undergo endoscopy after initial resuscitation within 24 hours of presentation without anticoagulation reversal unless INR supratherapeutic, INR greater than 3.

Front 26

when to do second look endoscopy?

Back 26

– suboptimal first exam
– for rebleeding prior to considering surgery or interventional radiology
– to rule out malignancy (6–8 weeks later) when biopsies of the ulcer were not performed during the initial endoscopy ie d/t bleeding

Front 27

When should nonselective beta blocker to be used in hepatic varices?

Back 27

Only when medium or large varices are present or varices with a high likelihood of bleeding. Cirrhosis patients without varices should be periodically screened with upper endoscopy only.

Front 28

What is a pseudoaneurysm?

Back 28

Acute and chronic pancreatitis can be associated with pseudocyst formation, which can erode into adjacent artery causing pseudoaneurysm and bleeding.

Front 29

Best measures of acute blood loss?

Back 29

–Tachycardia
–Hypotension/Orthostasis

With acute blood loss, RBCs and plasma are lost concurrently so that hematocrit and hemoglobin do not reflect the magnitude of blood loss.

Front 30

Treatment of variceal bleeding

Back 30

–Airway protection
–two large bore catheters
–Resuscitation with IV fluids
–Hemoglobin less than seven absolute indication for RBC transfusion
–IV octreotide
–Anabiotics

Front 31

When to do angiography and how much blood loss required to detect?

Back 31

Should only be performed in patients with active overt bleeding, as it requires a bleeding rate greater than 1 ml/minute

Sensitivity of angiography is generally poor and complications such as kidney failure, organ necrosis vascular dissection/aneurysm can occur.

Front 32

How much blood loss required to dectect GIB on RBC scans?

Back 32

Provides the best sensitivity for actively bleeding lesions. Only requires 0.5 mL per minute blood loss.

But scan nonspecific–often do not disclose a specific site of bleeding and don't allow for intervention.

Front 33

Treatment of upper G.I. bleed

Back 33

–Volume stabilization first
–Localization of bleeding site: EGD
–High dose PPI: protonix 80 mg IV bolus followed by 8 mg per hour times 48 hour
–Octreotide infusion, if history of liver disease or findings suggestive of portal hypertension due to likely variceal bleeding

Front 34

Causes of lower G.I. bleed

Back 34

1. Colonic diverticula
2. Angiodysplasia

RX:
–Rule out upper G.I. bleed by passing NG tube with aspiration but NG aspiration can miss upto 15% of UGIBs.

Front 35

Diverticular bleed

Back 35

–Bleeds mostly from the right side
–Usually single large bleed with sudden stop

Pearls:
–surgical resection if intractable bleeding or > 2 large bleeds in six months.

Front 36

Pt with ulcer. During endoscopy what treatment should be done and when can the patient be discharged?

Back 36

adherent clot → irrigate, treat endoscopically

Clean base →low risk → oral PPI, early d/c

active spurt or visible vessel→high risk – epi, clip, IV PPI for 3 days then oral

Front 37

Obscure GI bleed, first step?

Back 37

repeat upper endoscopy and/or colonoscopy often identifies the cause of bleeding.

Front 38

caveats for angiography and technetium–labeled nuclear scans for obscure GI bleed?

Back 38

both only good when there is ACTIVE bleeding
– Angiography (diagnostic and therapeutic)
– tech (therapeutic only, more sensitive, good first test)

Front 39

Things to think about when offering primary prevention for large esophageal varices:

Back 39

The choice will always be between nonselective beta blockers versus ligation. Generally beta blockers unless contraindication to beta blocker such as asthma/COPD/bradycardia.

Front 40

Patient with upper GI bleed and hx of aortic stenosis, what to consider?

Back 40

If EGD shows multiple angioectasia, consider (Heyde syndrome).

- Valve replacement indicated to stop bleeding