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796 Cards in this Set

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  • Back
Q001. (3) causes of viral Esophagitis
Q002. (5)* causes of Bacterial Esophagitis
A002. My Pnew Strep Lacts Crypt:; Mycobacterium TB;; Pneumocystis Carnii;; Strep;; Lactobacillus;; Cryptospordium
Q003. *When is a Barium Esophagram the best initial test?; when is it the most accurate?; (3)
A003. Dysphasia (that shows no signs of obstruction...for obstruction it would be Upper Endoscopy); most accurate:; 1. Esoph Webs; 2. Esoph Rings; 3. Esoph Diverticuli
Q004. Dx: Odynophagia (pain with swallowing), dysphagia, esophageal bleeding, N/V, chest pain, (or asymptomatic)
A004. Infectious Esophagitis
Q005. Dx: Infectious esophagitis with nodular filling defects on barium esophagram; Tx?
A005. Candida; Tx: Fluconazole PO
Q006. Causes: Infectious esophagitis with vesicles and descrete erosions on endoscopy; (2); Tx?
A006. HSV or VZV; Tx: Acyclovir for HSV
Q007. Dx: Infectious esophagitis with intranuclear inclusions on biopsy via endoscopy; Tx?
A007. CMV; Tx: Ganciclovir IV
Q008. Who should upper endoscopy screening be offered to?; (2)
A008. 1. Patients with GERD and Symptom for > 5 years (to check for Barrett's esophagus); 2. Patients with Esophageal varices
Q009. Dx: A Full-thickness tear usu in the weak left posterolateral wall of distal esophagus; (3) causes?
A009. Boerhaave's Syndrome; Causes:; Forceful vomiting;; Cough;; Trauma
Q010. Dx: A Partial-thickness tear usu in the right posterolateral wall of the distal esophagus and results in bleeding that resolves spontaneously; Cause?
A010. Mallory-Weiss syndrome; Cause: Forceful vomiting
Q011. medical Tx for non-bleeding Esophageal Varices
A011. Propranolol
Q012. What is the next step in the Tx of a patient with GERD that has persistent Symptom after 4 weeks of Tx with a PPI?
A012. 24-hour Esophageal pH recording
Q013. If patient has mediastinal and subcutaneous emphysema, what esophageal problem do they have?
A013. Full-thickness tear; (Boerhaave's syndrome)
Q014. Dx sign: "Crunching sound" heard with heartbeat; what is it due to?
A014. "Hammon's crunch" (Mediastinal emphysema); From: Full-thickness esophageal tear (Boerhaave's syndrome)
Q015. *What is the Diagnostic test of choice for Boerhaave's syndrome or a partial esophageal perforation?; What is the most accurate test?
A015. Dx test: Gastrograffin (water-soluble contrast); most accurate: CT scan
Q016. Tx for esophageal tear; (1 for each type)
A016. Partial-thickness (Mallory-Weiss): may resolve spontaneously; Full-thickness (Boerhaave's): Surgery
Q017. Definition: Pharyngeal or esophageal pouch due to a defect in the muscular wall of the posterior hypopharynx
A017. Zenker's Diverticulum
Q018. Dx: Halitosis, regurgitation of food after eating it, frequent aspiration, esophageal obstruction
A018. Zenker's Diverticulum
Q019. Dx test for Zenker's Diverticulosis; (2 possible); Tx (2 possible)
A019. Tests: Barium swallow;; Endoscopy; Tx:; Surgical removal;; Cricopharyngeal myotomy
Q020. Dx: 56-yo man complains of food feeling "stuck" on its way down and vomiting food he ate days ago
A020. Zenker's Diverticulum
Q021. Definition: Neurogenic disorder of esophageal motility with absence of normal peristalsis and impaired relaxation of the LES
A021. Achalasia
Q022. Definition: Esophageal motility disorder with frequent non- peristaltic contractions
A022. Diffuse Esophageal Spasms; (DES)
Q023. What esophageal problem affects 70% of people with Scleroderma?
A023. Achalasia
Q024. What type of problem does dysphagia to solids and liquids indicate?; (2 examples); To just solids?; (3 examples)
A024. Solids + Liquids: Motility problem (Achalasia; DES); Solids only: Mechanical problem (Tumor; Schatzki's ring; Plummer-Vinson syndrome)
Q025. Dx: weight loss, cough, dysphagia of both solids and liquids, "bird's beak" on CXR; Tx options?; (2 drugs and 2 procedures)
A025. Achalasia; Tx options:; Nitroglycerin;; Local Botulinum toxin;; Balloon Dialation;; Sphinctor Myotomy
Q026. Dysphagia to both solids and liquids, diffuse chest pain, "corkscrew" appearance on CXR; DES Drug Tx options? (2 possible)
A026. Diffuse Esophageal Spasms (DES); Tx options:; 1. Nitroglycerin;; 2. Anticholinergics
Q027. When is an Esophageal Manometry the test of choice?; (2)
A027. 1. an Inconclusive Barium or upper endoscopy; 2. Description of a Motility problem (Achalasia, DES, Nutcracker esophagus)
Q028. Etiology of Achalasia; (2)
A028. Scarring of Auerbach's plexus from: Chagas Disease; or Ganglionic degeneration
Q029. Definition: Hypopharyngeal webs (thin mucosal structures protruding into lumen of the esophagus) associated with iron deficiency anemia
A029. Plummer-Vinson Syndrome
Q030. Definition: Narrow lower esophageal ringlike outgrowth associated with dysphagia
A030. Schatzki's Ring
Q031. Etiology of GERD; (4)*
A031. HIDE:; Hiatal hernia;; Incompetent LES tone; Delayed Gastric emptying;; Esopageal motility decreased
Q032. (5)* causes of Delayed Gastric Emptying
A032. Delayed Food GAG: DM;; Fatty foods;; Gastroparesis;; Anticholinergics;; Gastric outlet obstruction
Q033. (8)* causes of a decreased LES tone
A033. Coffee CAN Cause Esophageal Sphinctor Problems:; Coffee;; Chocolate;; Alcohol;; Nitrates;; Calcium channel blockers;; Estrogen;; Smoking;; Progesterone
Q034. Differential of Chronic Cough; (3)*
A034. GAP in breathing:; GERD;; Asthma / Chronic Bronchitis;; Post-nasal drip
Q035. Dx: Substernal chest pain, dysphagia, hypersalivation, cough, wheezing
A035. GERD
Q036. What (3) lifestyle modifications should be told to patients with GERD?
A036. Discontinue foods that lower LES tone;; Elevate head of bed;; No food < 3 hours before bed
Q037. (2) drug Tx options for GERD; What can be done if medication doesn't work?
A037. Proton Pump Inhibitor (1st);; H-2 Blocker; Final solution: Surgical fundoplication
Q038. Definition: Esophageal damage, bleeding and friability due to prolonged exposure to gastric contents
A038. Esophagitis
Q039. (4)* complications of GERD
A039. BEEP:; Barrett's Esophagus;; Esophagitis;; Esophageal cancer;; Peptic stricture
Q040. (2) types of esophageal cancers and where each is formed in esophagus
A040. Squamous: Upper 2/3 of esophagus; Adenocarcinoma: Lower 1/3 of esophagus
Q041. Risk factors for CA of the esophagus; (7)*
A041. ABCDEF:; Alcohol;; Barrett's esophagus;; Cigarettes;; Diverticuli (Zenker's);; Esophageal web (P-V synd), Esophagitis (reflux or irritants);; Familial
Q042. What causes Barrett's?; What can it become?; How often should a patient with Barrett's have an upper endoscopy?
A042. BARRett's: Becomes Adenocarcinoma, Results from Reflux; UE: Barrett's: every 2 - 3 years
Q043. What is the Alkaline Tide?
A043. Parietal cells secreting HCl into the gastric lumen and bicarb into the gastric venous circulation, which goes to the gastric mucous cell
Q044. What hormones/NT stimulate parietal cells?; (3)
A044. Holds Gastric Acid:; Histamine (H-2);; Anticholinergic (from vagus);; Gastrin
Q045. What hormone stimulates release of Gastrin? From what cells and where?
A045. Gastrin-releasing peptide; (from G-cells in antrum of stomach)
Q046. What hormone inhibits Gastrin? From which cells?
A046. Somatostatin; (from D-cells in the pancreas and GI mucosa)
Q047. What inhibits the Gastric Bicarb secretion (from the alkaline tide) from entering the mucous gel to line the stomach?; (4)
A047. NSAIDs;; Alcohol;; Acetazolamide;; Alpha-blockers
Q048. What increases the thickness of the mucous gel of the stomach?; What decreases it?; (2)
A048. Increases: Prostaglandin E; Decreases (by inhibiting PGE): NSAIDs; Steroids
Q049. Dx: A patient has large, multiple ulcers that are recurrent and distal in origin. First test?; What are diagnostic levels?; if this Dx is still suspected and diagnostic levels of the first test are not reached, what is the next test?; what syndrome is it assoc with?
A049. Zollinger-Ellison syndrome; First test: Gastrin Level (> 1,000pg/mL is diagnostic); Next if not at Dx level: Secretin Stimulation test (Gastrin levels will still be high); Assoc with: MEN-1
Q050. Dx: 52-yo woman presents with 3 months of early satiety, weight loss, and vomiting
A050. Gastric Outlet Obstruction
Q051. Definition: Syndrome involving a gastrin-secreting tumor in or near the pancreas
A051. Zollinger-Ellison Syndrome
Q052. Triad of Zollinger-Ellison syndrome
A052. PUD;; Elevated Gastrin levels;; Gastric Acid hypersecretion
Q053. Dx: Burning epigastric pain that is releived within 30 minutes of ingesting food; causes nighttime awakening, N/V, possible melena; What blood type is it associated with?
A053. Duodenal Ulcer; (better after eating); (blood type O)
Q054. If an ulcer is found on endoscopy, what is the test of choice to see if it is H.pylori?; After treatment of H.pylori with a PPI, what is the best test if the patient still has symptoms or to confirm eradication of the bug?
A054. if ulcer is found: Biopsy; No change after PPI: Urease Breath test
Q055. What from H.pylori decreases the gastric mucosal defenses?
A055. Urease
Q056. Dx Test for Zollinger-Ellison?
A056. Secretin stimulation test; (if gastrin levels are still high after this inhibitor, then probable ZE)
Q057. Triple therapy for H. pylori
A057. CAP:; Clarithromycin; Amoxicillin; Proton Pump inhibitor
Q058. If patient is bleeding from an ulcer, what is drug Tx after endoscopy?; (2 possible plus MOA)
A058. Sucralfate (enhances mucosal barrier); or Misoprostol (prostaglandin analog)
Q059. 45-yo Japanese male smoker presents with epigastric pain, exacerbated by eating, and weight loss
A059. Gastric Ulcer
Q060. Dx: burning epigastric pain that occurs within minutes after eating, anorexia, vomiting; What blood type is it associated with?
A060. Gastric Ulcer; (worse after eating); (blood type A)
Q061. Dx test for Gastric Ulcers
A061. Endoscopy with Biopsy; (all confirmed GU are Biopsy due to risk of CA)
Q062. Type of PUD related to an increase in acid production?
A062. Duodenal Ulcer
Q063. Type of PUD that can occur with achlorhydria?
A063. Gastric Ulcer
Q064. Best Tx for Gastritis or any ulcer of unknown etiology; (3 together)
A064. Combo:; 1. Mucosal protector (Bismuth, Sulcrafate, Misoprostol); 2. H-2 blocker or Proton pump inhibitor; 3. Antibiotics for H. pylori (amoxicillin; clarithromycin)
Q065. Dx: burning, gnawing epigastric pain usually worse with food and relieved with antacids
A065. Gastritis
Q066. Etiology of Gastritis; (8)
A066. GNASHING pain:; Gastric reflux (of bile or pancreatic secretions);; Nicotine;; Alcohol;; Stress;; H. pylori;; Ischemia;; NSAIDs;; Glucocorticoids (long-term use)
Q067. Difference b/t acute and chronic gastritis
A067. Acute: Erosive; Chronic: Non-erosive
Q068. Difference b/t the causes of the (2) types of Chronic Gastritis; where is each located in stomach?
A068. A = A's / B = Bug; Type A (Fundal): Auto-Ab to parietal cells; Anemia (pernicious); Achlorhydria;; Type B: Bug = H. pylori
Q069. what is the inflammation of the pancreas due to?; (2)
A069. - Autodigestion by proteolytic enzymes; Systemic Inflammatory Response Syndrome (SIRS) (severe cases)
Q070. Exocrine (5) and Endocrine (3) secretions of the pancreas
A070. Exocrine:; Bicarbonate;; Amylase;; Lipase;; Tyrosine;; Proteases (trypsin, carboxypeptidase, etc) Endocrine:; Glucagon;; Insulin;; Somatostatin
Q071. (2) most common causes of pancreatitis
A071. Gallstones; Alcohol
Q072. Dx: patient with a history of alcohol abuse has abdominal pain & calcifications on abd x-ray
A072. Chronic pancreatitis
Q073. Etiology of Acute Pancreatitis; (7)
A073. G-HEADS:; Gallstones;; Hypertriglycerides; HyperC;; Endoscopic Retrograde Cholangiopancreatogrophy (ECRP);; Alcohol;; Drugs;; Structural (neoplasm)
Q074. (4) drugs that can cause acute pancreatitis
A074. FEAT:; Furosemide;; Estrogen;; Antiretrovirals;; Thiazides
Q075. Dx: constant mid-epigastric or LUQ pain that radiates to the back; may improve if patient sits-up and leans forward. N/V, fever, tachypnea, abd is tender with guarding
A075. Acute pancreatitis
Q076. What is the most specific (and initial test) for Pancreatitis?; Most accurate?; If Pancreatic Necrosis is seen, what is the next step?
A076. most specific: Lipase (will be 2x normal); most accurate: CT scan; if necrosis: Pancreatic Biopsy
Q077. Dx: 50-yo male alcoholic presents with mid epigastric pain radiating to the back. He is leading forward on the stretcher and vomiting
A077. Acute Pancreatitis
Q078. Dx: a 66-yo female with HTN and seziures is on furosemide and valproic acid, presents with abdominal pain, back pain and fever. Her non-fasting glucose is 300
A078. Acute Pancreatitis
Q079. (4) Dx tests for pancreatitis
A079. Abdominal x-ray;; Ultrasound (gallstone cause);; ERCP (visualize sphinctor);; Contrast-Enhanced CT (shows pancreatic necrosis)
Q080. Define: Sentinel loop; what is it associated with in pancreatitis?
A080. Distention and/or air-fluid levels near a site of abdominal distention. In pancreatitis, it is secondary to pancreatitis-associated Ileus
Q081. Tx for acute Pancreatitis; (4 together)
A081. 1. IV hydration;; 2. Bowel rest – Antiemetics (NG tube for vomiting or associated ileus);; 3. Analgesics;; 4. Antibiotics (Imipenem) for suspected infection
Q082. What can occur in acute pancreatitis if left untreated in:; 1. < 48 hours; 2. 1 - 4 weeks; 3. 4 - 6 weeks
A082. 1. Pleural effusion of pancreatic fluids; 2. Pseudocyst; 3. Abscess (needs surgical drainage)
Q083. What on a physical exam will indicate splenic vein thrombosis, a complication of pancreatitis?
A083. Gastric varices; (without esophageal varices)
Q084. MCC of Chronic pancreatitis
A084. Alcohol abuse
Q085. Dx: midepigastric pain that radiates to the back; malabsorption; steatorrhea; elevated blood sugars; polyuria
A085. Chronic Pancreatitis
Q086. the Secretin Stimulation test is used to Dx what (2) problems?
A086. 1. Zollinger-Ellison syndrome; 2. Chronic Pancreatitis
Q087. *What is the only test that is specific for a Dx of Chronic Pancreatitis from the Symptom of Steatorrhea?; When is it the "Next step"?
A087. Serum Trypsinogen (which will be low); Next step: After Sudan Black confirms malabsorption and if Antigliadin and anti-endomysial Ab are normal.
Q088. Describe the (2) signs of Hemorrhagic Pancreatitis:; 1. Grey Turner's sign; 2. Cullen's sign
A088. 1. Ecchymotic appearing skin on the flank; 2. same on the periumbilical area
Q089. What lab values in a patient are Very High with Obstructive liver disease?; Parenchymal liver disease?; (2)
A089. Obstructive: Alkaline phosphatase Parenchymal:; 1. PT; 2. ALT/AST
Q090. Definition: Chronic hepatic injury assoc with hepatic necrosis, fibrosis and nodular regeneration
A090. Cirrhosis
Q091. A patient with alcoholic cirrhosis comes in vomiting blood. He is stabilized with fluid. What is the next step?
A091. Octreotide
Q092. MCC of cirrhosis in USA?; worldwide?
A092. USA: Alcohol abuse; world: Hepatitis
Q093. Dx: spider nevi, gynecomastia, loss of sexual hair, asterixis, bleeding tendency, Dupuytren's contracture, encephalopathy, portal HTN, jaundice
A093. Cirrhosis of the Liver
Q094. What are the causes in the following symptoms that are diagnostic of liver cirrhosis:; 1. Bleeding; 2. Encephalopathy; 3. Ascites, melena, edema
A094. 1. Decreased clotting factors made in the liver; 2. Increased ammonia; 3. Portal HTN
Q095. Order of the (4) liver problems (Dx names) caused by increasing alcohol consumption
A095. Alcoholic Fatty Liver -> Alcoholic Cirrhosis -> Alcoholic Hepatitis -> Necrosis
Q096. Most sensitive serum marker for recent alcohol bingeing
A096. GGT
Q097. Rx for the following Symptom in Alcoholic liver cirrhosis:; 1. Decrease inflammation (2); 2. Ascites; 3. Hepatic encephalopathy (2); 4. Esophageal varices (2)
A097. 1. Glucocorticoids and Colchicine; 2. Spironolactone; 3. Lactulose and Neomycin; 4. Beta-blocker or IV somatostatin (or banding or balloon tamponade)
Q098. (3)* metabolic diseases that cause Liver Cirrhosis. Name the test markers that would indicate the Disease as the cause
A098. Will Agitate Hepatocytes:; 1. Wilson's Disease (high serum Ceruloplasmin); 2. Alpha-1-antitrypsin deficiency (serum electrophoresis with absence of alpha-globulin); 3. Hereditary Hemachromotosis (Fasting Transferrin Saturation = high Ferritin and TIBC)
Q099. Why would the BUN be lower in liver cirrhosis?
A099. Decreased protein production
Q100. Test marker that indicates cirrhosis with hepatocellular CA
A100. Increased Alpha-fetoprotein
Q101. Definition: Autoimmune disease causing destruction of the intrahepatic ducts
A101. Primary Biliary Cirrhosis
Q102. Dx: 40-yo woman with scleroderma is admitted with jaundice, pruritis and xanthomas; What is the serologic hallmark?
A102. Primary Biliary Cirrhosis; (Anti-mitochondrial Ab)
Q103. (2) autoimmune disorders assoc with Primary Biliary Cirrhosis
A103. Scleroderma; Sjogren's syndrome
Q104. What drug Tx will slow the progression of Primary Biliary Cirrhosis?; What is only cure?
A104. Ursodiol (synthetic bile acid); Cure: Liver Transplant
Q105. MCC of Portal HTN worldwide
A105. Schistosomiasis
Q106. Signs of Portal HTN; (5)*
A106. CHASE:; Caput medusa;; Hemorrhoids;; Ascites;; Splenomegaly;; Esophageal Varices
Q107. Tx for Portal HTN; (4)
A107. Propranolol to reduce pressure;; Portosystemic shunt surgery;; TIPS - shunt b/t hepatic and portal veins;; Liver transplant
Q108. Dx: Liver disease, joint pain, Diabetes, cardiomyopathy, skin hyperpigmentation and infertility. First test?; what is the confirmatory test?
A108. Hereditary Hemochromatosis; first test: Fasting Transferrin saturation; Confirmatory: HFE Gene and C282Y mutation (eliminates the need for liver Biopsy in HH)
Q109. GI functions of Somatostatin; (6)
A109. Inhibits:; Visceral blood flow; Gastric acid secretion; Gastric motility; Gallbladder emptying; Pancreatic enzyme and bicarbonate secretion; Intestinal absorption of glucose, water, AA, and triglycerides
Q110. Hepatic encephalopathy is precipitated by what?; (3)*
A110. PIG:; Protein (dietary) increase;; Infection;; GI bleed
Q111. Signs/Symptom of Hepatic Encephalopathy; (3)
A111. Fetor Hepaticus (Corpse breath);; Asterixis;; Mental status change or coma
Q112. In a patient with bleeding esophageal varices, after stabilizing IV fluids, what is the next step?
A112. Octreotide
Q113. Tx for Hepatic encephalopathy; (3)
A113. Protein restriction;; Lactulose (to change NH3 to NH4 so it cant cross BBB); Neomycin (for gut bacteria that make NH3)
Q114. MCC of Spontaneous Bacterial Peritonitis (bug)
A114. E. coli
Q115. Dx: Patient with ascites, fever, chills, abdominal pain with rebound, may progress to sepsis
A115. Spontaneous Bacterial Peritonitis
Q116. Dx test for Spontaneous Bacterial Peritonitis; Tx?
A116. Test: Paracentesis (abdominal tap); Tx: Gram-negative coverage (Cefuroxime)
Q117. Definition: Systemic infection of the liver due to viral agents, toxins, or alcohol
A117. Hepatitis
Q118. Mode of transmission of Hepatitis: A, B, C, D, E, G
A118. A and E - fecal-oral route; B, C, D, G - sex and blood
Q119. Which forms of hepatitis are associated with:; 1. IV drug use (2); 2. Unprotected sex; 3. Overseas travel (2)
A119. 1. HBV and HCV; 2. HBV; 3. HAV and HEV
Q120. What (2) toxins cause hepatitis?
A120. Acetaminophen; Aflatoxin
Q121. *Viral class for:; 1. HAV; 2. HBV; 3. HCV; 4. HDV; 5. HEV; Which is the only DNA virus?
A121. Please Help Find Danielle's Cat:; 1. Picorna; 2. Hepadna; 3. Flavi; 4. Delta; 5. Calici; HBV is DNA (the rest are RNA)
Q122. Meaning of HAV antibodies; (2)
A122. HAV IgM = Acute infection; HAV IgG = Immunity from prior infection
Q123. Prevention of HAV?; Tx of HAV?
A123. Prevention: Anti-HAV Ig is 90% effective if given within (2) weeks of exposure; Tx: symptomatic
Q124. How is hepatotoxicity from Acetaminophen prevented if detected early?
A124. N-acetylcysteine
Q125. Meaning of HBV antibodies in order of detection (4)*; Which signifies the "window period"?; Which indicates immunity?
A125. SAGing BAG-E / Camels May / Spit and Gag:; HBsAg positive = infection is present; HBeAg = Chronic hepatitis; Anti-HBc IgM = infection is acute (window period); Anti-HBs IgG = past infection or vaccine (indicates immunity)
Q126. Exposure scenarios: What is Tx to a newborn exposed with Hepatitis B?; Adult infected blood exposure?
A126. Newborn: Give HBIG and vaccine; Other: Test for HBV, if negative give HBIG only
Q127. Tx for HBV; What does HBV give patient a risk of developing?
A127. Lamivudine; Risk: Hepatocellular cancer
Q128. Meaning of "HCV antibody"
A128. Anti-HCV IgG = indicates chronic or past infection
Q129. Tx for HCV; (2)
A129. Interferon; Ribavirin
Q130. What do 25% of the chronic HCV patients develop?; (2)
A130. Cirrhosis; and/or Hepatocellular CA
Q131. Dx: Medical student develops fever, jaundice and fatigue 2 weeks after returning from a trip to India
A131. Hepatitis E
Q132. A young female is diagnosed with liver disease, but does not drink, have inflammatory bowel disease or infectious hepatitis. Next test?; if positive, what is the Dx?; What additional immune marker is assoc with it?
A132. Next test: Anti-Smooth Muscle Ab (ASMA); Dx: Autoimmune Hepatitis; Additional immune marker: Anti-Liver/Kidney Microsome type 1 Ab (anti-LKM1 Ab)
Q133. Indications for Liver transplantation; (5)
A133. Cirrhosis;; Primary Sclerosing Cholangitis;; Chronic Hepatitis;; Hepatocellular CA;; Hepatic Vein Thrombosis
Q134. What must match with donor liver?; (2)
A134. Size and ABO; (not Rh or HLA)
Q135. (3) medications for Immunosuppression of Liver recipients
A135. Cyclophosphamide;; OKT3;; Tacrolimus
Q136. What stimulates the gallbladder contraction (specifically)
A136. Fat and Amino Acids in the proximal duodenum causes release of CCK
Q137. Dx: Middle-aged female patient presenting with pruritis and an elevated Alkaline phosphatase with a normal Bilirubin. What is the best initial test?; what is the most accurate test?
A137. Dx: Primary Biliary Cirrhosis; initial test: Anti-mitochondrial Ab test; most accurate: Liver Biopsy
Q138. Risk factors for cholelithiasis; (8 F's); Two others?
A138. Female;; Fat;; Forty;; Fertile;; Fibrosis (Cystic);; Familial;; Fasting;; F-Hgb (Sickle cell); Also: DM and Oral contraceptives
Q139. Dx: RUQ pain that lasts 2-6 hours, most often after fatty meal, N/V, RUQ tenderness without guarding or rebound
A139. Cholelithiasis
Q140. What labs are elevated with gallstones?
A140. Alkaline phoshatase; Bilirubin; (direct more then indirect)
Q141. when should HIDA scan be answered?; (2)
A141. 1. Gallstones and US Murphy's sign without Gallbladder edema; 2. Gallbladder edema and US Murphy's sign without Gallstones (if Dx is obvious, then do not answer HIDA scan)
Q142. First Dx test of choice for gallstones?
A142. Ultrasound
Q143. Out of the (3) types of gallstones, name them in least common to most.
A143. 1. Cholesterol (10%); 2. Pigment (20%); 3. mixed (70%)
Q144. When are Radiolucent cholesterol gallstones seen?; (3)
A144. rapid weight loss;; Oral contraception;; Ileal disease
Q145. When are radiodense pigment gallstones seen?
A145. Hemolysis
Q146. Treatment of gallstones in order; (1 med; 2 procedures)
A146. 1. Chenodeoxycholate; 2. Lithotripsy; 3. Cholesystectomy
Q147. Dx: Patient has high fever, chills, RUQ abdominal pain and jaundice. She has a history of ULCERATIVE COLITIS and is complaining of pruritus with a negative hepatitis profile and a negative US. Next step?
A147. Dx: Primary Sclerosing Cholangitis; next step: ECRP
Q148. (4) bugs that can cause cholecystitis
A148. BEEK:; Bacteriodes; E.coli; Enterococcus; Klebsiella
Q149. Dx: RUQ pain often longer then 6 hours, possible guarding and rebound, fever, tachycardia, + Murphy's sign
A149. Cholecystitis
Q150. Sign: the arrest of inspiration while palpating the RUQ. what is the Dx if positive?
A150. Murphy's sign; Dx: Acute cholecystitis
Q151. Dx test of choice for cholecystitis
A151. HIDA: labeled iminodiacetic acid is injected IV and taken up by hepatocytes. Normal gallbladder is outlined in 1 hour, absence of visable gallbladder = cholecystitis
Q152. What condition is an ERCP most accurate for?
A152. Primary Sclerosing Cholangitis
Q153. Tx for cholecystitis in order; (2 meds; 1 procedure)
A153. Pain control;; 2nd or 3rd generation Cephalosporin;; Cholecyctectomy
Q154. Definition: complete obstruction of the biliary outflow tract due to a stone obstructing the common bile duct, a stricture or tumor. The patient becomes septic and it is life threatening
A154. Ascending cholangitis
Q155. Definition: stone obstruction of the common bile duct
A155. Choledocholelithiasis
Q156. Charot's triad of Ascending Cholangitis; Reynolds pentad?
A156. Charot's triad:; RUQ pain;; Jaundice;; Fever Reynold's pentad: above plus; Shock (hypotension);; Altered mental status
Q157. *Tx of choice for Ascending cholangitis
A157. ERCP with endoscopic sphinctorotomy
Q158. Definition: Chronic progressive disorder of unknown etiology characterized by inflammation, fibrosis, and strictures of the intrahepatic and extrahepatic biliary tree. What is it associated with?
A158. Primary sclerosing Cholangitis; Associated with: Ulcerative Colitis
Q159. Dx: 34-yo man with a history of ulcerative colitis presents with jaundice and elevated GGT and alk-phos.
A159. Primary Sclerosing Cholangitis
Q160. ERCP showing "beads on a string" appearance
A160. Primary Sclerosing Cholangitis
Q161. Pathogenesis of cholelithiasis
A161. 3 types of stones:; cholesterol (from bile supersaturated with cholesterol, hypomotile gallbladder); black pigmented stones (seen in hemolytic disease and alcoholic cirrhosis), from unconjugated bili; brown stones: from biliary tract infection
Q162. clinical features of cholelithiasis
A162. most are asymptomatic; biliary colic
Q163. dx of cholelithiasis
A163. RUQ u/s
Q164. tx of cholelithiasis
A164. none needed unless repeated bouts of biliary colic, then tx with cholecystectomy
Q165. complications of cholelithiasis
A165. cholecystitis; choledocholithiasis; gallstone ileus; malignancy
Q166. pathogenesis of acute cholecystitis
A166. obstruction of cystic duct --> inflammation of gallbladder wall
Q167. clincal features of acute cholecystitis
A167. RUQ pain that may radiate to right shoulder; murphy's sign
Q168. dx of acute cholecystitis; what if initial study is negative?
A168. RUQ u/s: shows pericholecystic fluid; if u/s is negative, do HIDA scan to look for dye not filling gallbladder
Q169. tx of acute cholecystitis
A169. hydration, bowel rest, antibiotics, pain meds; cholecystectomy
Q170. complications of acute cholecystitis
A170. gangrenous cholecystitis; GALLBLADDER perforation; emphysematous cholecystitis; fistula with gallstone ileus
Q171. pathophysiology of gallstone ileus
A171. gallstone enters bowel lumen via fistula with gallbladder, gets stuck --> obstruction
Q172. pathogenesis of choledocholithiasis
A172. gallstone gets stuck in common biliary duct
Q173. what are the two types of stones seen in choledocholithiasis
A173. primary: pigmented, originate in common biliary duct; secondary: from gallbladder, then pass into common biliary duct, usually cholesterol or mixed
Q174. clinical presentation of choledocholithiasis
A174. most patients are asymptomatic for years; RUQ pain +/- jaundice
Q175. dx of choledocholithiasis
A175. ERCP (shows common biliary duct dilation)
Q176. tx of choledocholitiasis
A176. ERCP with sphincterotomy and stone extraction, stent placement
Q177. complications of choledocholithiasis
A177. cholangitis; pancreatitis; biliary cirrhosis
Q178. pathogenesis of cholangitis
A178. obstruction --> biliary stasis --> bacterial overgrowth and infection
Q179. clinical presentation of cholangitis
A179. charcot's triad (fever, RUQ pain, jaundice)
Q180. dx of cholangitis
A180. ERCP; hyperbilirubinemia; elevated lfts
Q181. tx of cholangitis
A181. iv antibiotics and IVF; once afebrile x 48 hrs, ERCP
Q182. complications of cholangitis
A182. hepatic abscess
Q183. risk factors for carcinoma of the gallbladder
A183. gallstone; fistulas; porcelain gallbladder
Q184. clinical findings of carcinoma of the gallbladder
A184. palpable gallbladder; jaundice; biliary colic; weight loss
Q185. tx of carcinoma of the gallbladder
A185. surgery, but 90% die within first year of dx
Q186. porcelain gallbladder
A186. transmural calcification of gallbladder, 50% risk of developing carcinoma of the gallbladder
Q187. pathogenesis of primary biliary cirrhosis
A187. destruction of the intrahepatic bile ducts, with portal inflammation and scarring; autoimmune disease
Q188. clinical presentation of primary biliary cirrhosis
A188. middle aged women with autoimmune disease; fatigue; pruritis; RUQ pain
Q189. dx of primary biliary cirrhosis
A189. Positive AMA; cholestatic liver function tests; elevated alkaline phosphatase; liver biopsy to confirm dx
Q190. tx for primary biliary cirrhosis
A190. urodeoxycholic acid slows the progression and relieves symptom; liver transplant is curative
Q191. pathogenesis of primary sclerosing cholangitis
A191. thickening of bile duct walls and narrowing of their lumens
Q192. clinical presentation of primary sclerosing cholangitis
A192. patient with ulcerative colitis, pruritis, and jaundice
Q193. dx of primary sclerosing cholangitis
A193. ERCP shows bead like strictures and dilations of intra and extra hepatic ducts
Q194. tx of primary sclerosing cholangitis
A194. ERCP + stent placement to relieve symptom; liver transplant is curative
Q195. complications of primary sclerosing cholangitis
A195. cholangiocarcinoma; recurrent cholangitis; portal HTN; liver failure
Q196. pathogenesis of cholangiocarcinoma
A196. tumor of extra or intrahepatic bile ducts; primary sclerosing cholangitis is a major risk factor
Q197. clinical presentation of cholangiocarcinoma
A197. 60 yo with obstruction jaundice and weight loss
Q198. dx of cholangiocarcinoma
A198. ERCP
Q199. tx of cholangiocarcinoma
A199. most tumors are unresectable; ERCP + stent placement can relieve symptoms
Q200. complications of cirrhosis
A200. portal HTN; hepatocellular failure
Q201. 2 most common causes of cirrhosis
A201. alcohol use; chronic hepatitis b and c
Q202. clinical features of portal HTN
A202. bleeding from varices - most life threatening; hemorrhoids; caput medusae
Q203. tx of portal HTN
A203. tips (transjugular intrahepatic portal systemic shunt) to lower portal pressure
Q204. what is the most common type of varices from portal HTN
A204. esophageal (90%) gastric (10%)
Q205. acute tx of varices
A205. hemodynamic stabilization (plus fluids); ligation/banding; endoscopy sclerotherapy; octreotide
Q206. long-term treatment of varices
A206. beta blocker to prevent rebleeding
Q207. etiologies of ascites
A207. increased portal HTN (hydrostatic pressure increased); decreased albumin concentration (decreases oncotic pressure)
Q208. how to differentiate the causes of ascites
A208. calculate the SAAG; if >1.1, then from portal HTN,; if <1.1, then from hypoalbumin state
Q209. tx for ascites
A209. bed rest, low sodium diet, and diuretics
Q210. pathophysiology of hepatic encephalopahthy
A210. ammonia accumulates because the liver is unable to detoxify it
Q211. clinical presentation of hepatic encephalopathy
A211. asterixis; fetor hepaticus
Q212. treatment of hepatic encephalopathy
A212. decreased protein diet; lactulose; neomycin (last resort) to decrease bacteria that produce ammonia
Q213. pathophysiology of hepatorenal syndrome
A213. decreased renal perfusion because RAAS gets activated from decreased BP in splanchnic circulation, so there is peripheral vasoconstriction --> poor renal perfusion
Q214. clinical features of hepatorenal syndrome
A214. azotemia; oliguria; hyponatremia; hypotension; low urine sodium
Q215. tx for hepatorenal syndrome
A215. octreotide + midodrine: palliative; liver transplant is the only cure
Q216. pathophysiology of spontaneous bacterial peritonitis
A216. portal HTN increases --> gut hypomotility, and bacterial overgrowth; bv become more permeable and bacteria enter mesenteric ln and then enter blood stream; ascites fluid becomes infected
Q217. organisms usually involved with spontaneous bacterial peritonitis
A217. usually monomicrobial (e coli, klebsiela, strep pneumo)
Q218. dx of spontaneous bacterial peritonitis
A218. pnml >250; ascites cx
Q219. tx of spontaneous bacterial peritonitis
A219. iv antibiotics
Q220. complications of spontaneous bacterial peritonitis
A220. hepatic abscess; hepatorenal syndrome; intestinal obstruction
Q221. pathophysiology of Wilson’s disease
A221. copper is normally excreted by the liver, but in Wilson’s disease, there is a ceruloplasmin deficiency (required for excretion) so cu builds up; cu accumulates in hepatocytes, causing them to die and release cu into plasma and accumulate in kidney, cornea, and brain
Q222. clinical features of wilson's disease
A222. hepatitis; cirrhosis; fulminant hepatic failure; kayser'-fleischer rings; extrapyramidal signs; psych disturbances (depression, neurosis, psychosis, personality changes)
Q223. dx of wilson's disease
A223. elevated aminotransferases; low ceruloplasmin levels; liver biopsy shows elevated cu
Q224. tx for wilson's disease
A224. chelating agents (penacillamidene - removes and detoxifies cu deposits); Zn (prevents dietary uptake of cu); liver transplant
Q225. pathophysiology of hemochromatosis
A225. excessive Fe absorption in intestines --> Fe accumulation
Q226. organs affected by hemochromatosis
A226. liver; pancreas; skin; heart; joints
Q227. clinical features of hemochromatosis
A227. liver disease; fatigue; arthritis; abdominal pain; cardiac arrhythmias
Q228. complications of hemochromatosis
A228. cirrhosis; cmp; arthritis; DM; bronzing of the skin
Q229. dx of hemochromatosis
A229. liver biopsy required for dx
Q230. pathogenesis of appendicitis
A230. lumen of appendix is most commonly blocked by hyperplasia of lymphoid tissue or fecalith; obstruction --> stasis --> bacterial overgrowth and inflammation
Q231. pathogenesis of ruptured appendix
A231. distension of appendix can compromise blood supply and can lead to infarction or necrosis; necrosis --> perforation and peritonitis
Q232. imaging to dx appendicitis
A232. CT most sensitive and specific; Ultrasound
Q233. pregnant woman with suspected appendicitis
A233. surgery despite risk of false positive because risks are too severe
Q234. most common site for carcinoid tumor
A234. appendix
Q235. location of carcinoid tumor if it is malignant
A235. ileal tumor
Q236. pathogenesis of acute pancreatitis
A236. inflammation of pancreas from autodigestion of the pancreas
Q237. causes of acute pancreatitis
A237. GET SMASHeD; Gallstones; EtOH; Trauma; Steroids; Mumps; Autoimmune disease; Scorpion; Hypercalcemia, Hyperlipidemia; Drugs
Q238. which is more specific in acute pancreatitis: amylase or lipase
A238. lipase
Q239. what is the purpose of liver function tests in acute pancreatitis
A239. to ID cause (esp if related to gallstones)
Q240. role of abdominal radiographs in acute pancreatitis
A240. used to rule out other dx; calcifications suggests chronic pancreatitis; can sometimes see sentinel loop (air filled bowel in LUQ that demonstrates localized ileus)
Q241. role of u/s in acute pancreatitis
A241. to ID gallstones; can be used to follow pseudocyst or abscess
Q242. which is the test of choice for dx of acute pancreatitis
A242. ct
Q243. indication for ERCP in acute pancreatitis
A243. if it is from severe gallstone pancreatitis with biliary obstruction; to id uncommon causes of acute pancreatitis if disease is recurrent
Q244. pathogenesis of pancreatic pseudocyst
A244. localized collection of necrotic hemorrhagic material rich in pancreatic enzymes; it lacks and epithelial lining
Q245. complications of untreated pseudocysts
A245. rupture infection, gastric outlet obstruction, fisual, hemorrhage and pancreatic ascites
Q246. dx of pancreatic pseudocyst
A246. CT
Q247. tx of pancreatic pseudocyst
A247. <5cm, observation; >5cm, drain
Q248. complications of acute pancreatitis
A248. pancreatic necrosis; pancreatic pseudocyst; hemorrhagic pancreatitis; ARDS; pancreatic ascites; pleural effusion; ascending cholangitis; pancreatic abscess
Q249. tx of acute pancreatitis
A249. NPO; IVF; pain control
Q250. pathogenesis of chronic pancreatitis
A250. continuing inflammation of pancreas, with fibrotic tissue replacing pancreatic parenchyma and alteration of pancreatic ducts --> irreversible destruction of pancreas
Q251. most common cause of chronic pancreatitis
A251. chronic alcoholism
Q252. presentation of chronic pancreatitis
A252. chronic epigastric pain + calcifications on plain abdominal films; steatorrhea, DM, and pancreatic calcifications
Q253. serum and amylase levels in chronic pancreatitis
A253. not elevated
Q254. appearance of chronic pancreatitis on ct
A254. calcifications and pseudocysts an be seen
Q255. appearance of chronic pancreatitis on ERCP
A255. chain of lakes appearance from areas of stricture and duct dilation throughout the pancreatic ducts
Q256. complications of chronic pancreatitis
A256. DM; narcotic addiction; malabsorption/steatorrhea; pseudocyst formation; pancreatic ductal dilation; b12 malabsorption; pancreatic carcinoma
Q257. non surgical tx for chronic pancreatitis
A257. narcotics for pain; NPO; pancreatic enzymes + h2 blockers; insulin; alcohol abstinence; frequent small low-fat meals
Q258. surgical tx for chronic pancreatitis
A258. pancreaticojejunostomy (drains the pancreatic ducts to decompress dilated ducts); pancreatic resection
Q259. most common location for pancreatic cancer
A259. pancreatic head
Q260. risk factors for pancreatic cancer
A260. cigarette smoking (most common); chronic pancreatitis; DM; heavy Etoh use; exposure to benzidine and b-naphthylamine
Q261. purpose of h2 blockers + pancreatic enzymes in chronic pancreatitis
A261. pancreatic enzymes inhibit CCK release and decrease pancreatic secretion after meals; h2 blockers inhibit gastric acid secretion, preventing degradation of pancreatic enzyme supplements by gastric acid
Q262. test for dx pancreatic ca
A262. CT; ERCP
Q263. tumor markers for pancreatic ca
A263. ca 19-9; CEA
Q264. Definition: Gluten-induced enteropathy in susceptible persons affecting the small bowel
A264. Celiac Sprue
Q265. What HLA is Celiac sprue?; (2)
A265. HLA DR3; HLA DQw2
Q266. Dx: Malabsorption (diarrhea, bloating, abd pain, steatorrhea, weight loss), vitamin deficiency (high PT/INR, low iron and calcium), Rash
A266. Celiac sprue
Q267. Pathology Biopsy of small bowel: flattened intestinal villi, infiltration of lymphocytes, hyperplasia and lengthing of the intestinal crypts
A267. Celiac sprue
Q268. what does Antiendomysial Ab test?; What other test accompanies this one?; When is it performed?; What is the most accurate test for this Dx?
A268. Confirms Dx of Celiac Sprue; (also Antigliadin Ab test); Performed: After a Sudan Black stain confirms Malabsorption; Most Accurate: Small Bowel Biopsy; (must be done to Dx the disease and to RULE OUT Lymphoma)
Q269. Definition: A pruitic rash associated with Celiac sprue, responds to Tx of topical Sulfone, resolves with regression of disease
A269. Dermatitis Herpetiformis
Q270. Tx for Celiac sprue
A270. All grains are eliminated from diet except Rice and Corn; (no wheat rye or barley)
Q271. *Patient has chronic pale, greasy, malodorous diarrhea and no evidence of infection. Initial test?
A271. Sudan Black stain
Q272. Pathology Biopsy: mildly flattened intestinal villi with jejunal infiltration of monocytes
A272. Tropical sprue
Q273. Dx: malabsorption signs, megaloblastic anemia, decreased calcium, B-12, iron, folic acid, cholesterol, albumin and magnesium
A273. Tropical sprue
Q274. Tx for Tropical sprue; (2)
A274. Vitamin B-12 and Folate supplements; Tetracycline (for a few months)
Q275. Difference b/t Whipple's disease and Sprue
A275. Whipple's has CNS involvement
Q276. If there is the presence of a normal jejunal Biopsy, what malabsorption disease is ruled-out?
A276. Tropical sprue
Q277. Dx: 54-yo farmer who has been suffering with diarrhea, weight loss, and arthralgias for the past few months is brought in by his wife for memory deficits that have been occurring for the past 3 weeks.
A277. Whipple's disease
Q278. Definition: devastatingly profound malabsorption syndrome due to destruction of the intestinal lamina due to a gram- negative rod of the Actinomyces genus
A278. Whipple's Disease
Q279. Dx: arthralgia, abdominal pain, malabsorption, fever, inc skin pigment, uveitis, confusion, CNS palsies, nystagmus, heart failure
A279. Whipple's Disease
Q280. *Most accurate test for Whipple's Disease; Other test?
A280. Most accurate: PAS positive macrophages in the lamina propria;; other: PCR of peripheral blood for T. whippelii (Actinomyces strain)
Q281. Antibiotics Tx of Whipple's Disease; (2 steps)
A281. 1. initial course of Ceftriaxone; 2. TMP-SMZ and Tetracycline for 1 year
Q282. Definition: Albumin lost to the GI lumen in excess
A282. Protein-losing Enteropathy
Q283. Dx: Diarrhea, edema, steatorrhea, low albumin
A283. Protein-losing Enteropathy
Q284. Dx test for Protein-losing Enteropathy
A284. Alpha-1-Antitrypsin comparison in serum vs stool
Q285. Similar look to gastric cancer on barium study
A285. Menetrier's Disease
Q286. Definition: Protein-losing enteropathy that causes mucosal thickening due to hyperplasia of glandular cells replacing chief and parietal cells leading to enlarged, tortuous rugae
A286. Menetrier's Disease
Q287. Dx: epigastric pain, diarrhea, edema, steatorrhea, decreased gastric acid secretion, low albumin
A287. Menetrier's Disease
Q288. Dx Tests for Menetrier's Disease; (2)
A288. Endoscopy with deep mucosal Biopsy; Barium swallow will reveal large gastric folds
Q289. Rx Tx for Menetrier's Disease; (2 plus MOA of each specific to this)
A289. Anticholinergics (reduce width of tight junctions b/t gastric mucosal cells); H-2 Blockers (reduce protein loss)
Q290. Definition: Stool frequency < 3 times per week
A290. Constipation
Q291. Etiology of Constipation; (6)*
A291. OLD MD Farts:; Obstruction;; Low thyroid(hypothyroidism);; Disturbed colonic motility;; Medications;; DM;; Fluid and fiber intake is low
Q292. what amount should you increase your fiber to, if your are constipated?
A292. 30 g/day
Q293. Definition: Neuroendocrine tumor arising from ectodermal stem cells in the gut
A293. Carcinoid Tumor
Q294. MC place of a Carcinoid tumor
A294. 90% in Ileum; (most in appendix)
Q295. What neurotransmitters and hormones does the Carcinoid tumor secrete?; (3)
A295. Serotonin;; Bradykinin;; Histamine
Q296. MC places of mets with Carcinoid tumor; (2: in order of frequency)
A296. Liver;; Lung
Q297. Etiology of Carcinoid tumor; (2)
A297. Most are Idiopathic;; part of MEN-1
Q298. Classic triad of Carcinoid tumor and reason for each sign. (3) other signs
A298. 1. Flushing, Hypotension - Bradykinin; 2. Diarrhea - Serotonin; 3. Rt-sided Valvular heart Disease - Serotonin other:; Wheezing (histamine);; Bowel obstruction;; Appendicitis
Q299. Dx test for Carcinoid tumor; (2)
A299. 1. > 10mg/24 hour 5-HIAA; 2. elevated serum and urine 5-HT
Q300. Tx for Carcinoid tumor; (3)
A300. Surgical excision;; Radiation therapy;; Antihormonal therapy
Q301. What is a 72-hour Fecal Fat test?; When is the only time it is used?
A301. 72-hour FFT: Detects Intestinal Malabsorption; Only used: if you strongly suspect fat malabsorption and the Sudan Black stain is negative (best initial test for fat malabsorption is Sudan Black stain)
Q302. Type of GI cancer in the:; 1. Espophagus (2); 2. Duodenum and Jejunum; 3. Ileum (3)
A302. Esophagus: Squamous and Adenocarcinoma; Duodenum and Jejunum: Adenocarcinoma; Ileum: Carcinoid, Lipoma and Lymphoma
Q303. Definition: Aquired condition of the colon in which sac-like protrusions of colonic mucosa herniate through a defect in the muscular layer
A303. Diverticulosis
Q304. MCC of massive GI bleed in patients over 60-yo
A304. Diverticulosis
Q305. Dx: painless rectal bleeding; underlying Cause?
A305. Diverticulosis; inflammed diverticula erodes thru a colonic artery usually on RIGHT side
Q306. what is the non-Rx Tx for Diverticulosis?; if refractory?
A306. Bleeding scan and embolization;; Refractory: Surical removal
Q307. Difference b/t True and False Diverticula; which is more common?; on the right side (ascending colon)?
A307. True: herniation involving the full bowel wall thickness (right side and tend to bleed); False: only mucosal herniation thru muscular wall (more common)
Q308. Dx: LLQ pain, fever, high WBC, possible sigmoid mass
A308. Diverticulitis
Q309. Dx test for diverticulitis; What test should never be done?
A309. Abdominal CT; Never do Colonoscopy (risk of perforation)
Q310. Tx for Diverticulitis; (3 hospital management and 2 sets of choices for Antibiotics Tx)
A310. NPO, IV fluids, Pain control;; Antibiotics: FQ and Metronidazole; or Clindamycin and Gentamicin
Q311. MC fistula associated with Diverticular Disease; how does it present?
A311. Colovesicular; (presents with recurrent UTI)
Q312. MCC of nosocomial pseudomembranous colitis
A312. C. difficile
Q313. Dx: Crampy, diffuse abdominal pain, fever, watery (occasionally bloody) diarrhea; recent URI
A313. Pseudomembranous Colitis
Q314. Dx: 68-yo man in the hospital for 3 weeks for pneumonia returns with new-onset diarrhea
A314. C. difficile induced; Pseudomembranous Colitis
Q315. When is the only time Vancomycin is given PO?; What is the other Tx for this problem?
A315. Pseudomembranous colitis; also Tx with: Metronidazole PO
Q316. Dx tests for Pseudomembranous Colitis; (3)
A316. C. difficile toxin in stool;; Fecal Leukocytes;; Sigmoidoscopy (yellowish membranous plaques adhering to mucosa)
Q317. Dx: fluctuating constipation and diarrhea, increased with stress, lack of systemic symptoms
A317. Irritable Bowel syndrome
Q318. Tx for IBS; (2 together)
A318. 1. High-fiber / Low-fat diet;; 2. Antispasmotic / Antidiarrheal
Q319. What (2) Dx must be ruled-out when giving a Dx of IBS, because they present similarly?
A319. Giardia infection; Lactose intolerance
Q320. Between ULCERATIVE COLITIS and Crohn's, which is:; 1. More common in Men; 2. More common in women; 3. Greater risk for Colon CA
A320. 1. CD; 2. UC; 3. UC
Q321. What unusual topical Tx is there for Inflammatory Bowel Disease to improve Symptoms?
A321. Nicotine dermal patch
Q322. IBD: Inflammation of mucosa only
A322. UC
Q323. IBD: bloody diarrhea, rectal pain, more acute flares
A323. UC
Q324. IBD: tender RLQ mass, more chronic
A324. CD
Q325. IBD: Inflammation involves all bowel layers
A325. CD
Q326. IBD: Leads to fistulas, abscesses and involves granulomas
A326. CD
Q327. IBD: "Lead-pipe colon"
A327. UC
Q328. IBD: "Cobblestone appearance"
A328. CD
Q329. IBD: complications include perforation, stricture and megacolon
A329. UC
Q330. IBD: complications include abscess, fistula, perianal disease
A330. CD
Q331. (2) Drugs to Tx IBD that contain 5-ASA and Sulfapyridine; Which is also used to Tx Rheumatoid Arthritis?; Which only works in the colon?; Which works in the small bowel if taken orally,but need to be given by enema if needed for colon?
A331. Sulfasalazine: only in colon (also Tx: RA); Mesalamine: oral for small bowel and enema for colon
Q332. Tx for Inflammatory Bowel Disease; (5)*
A332. Inflam SCAM:; Immunomodulators;; Sulfsalazine;; Corticosteroids;; Antibiotics (Metronidazole);; Mesalamine
Q333. Which drug class for IBD works better for UC?
A333. Corticosteroids
Q334. Antibiotics Tx for Crohn's Disease
A334. Metronidazole
Q335. Immunomodulators used in Tx of Crohn's Disease; (4)*; Which is for severe cases?; Which (2) are purine analogs?
A335. MIA-6:; Methotrexate;; Infliximab (severe cases);; Azathioprine (purine);; 6-Mercaptopurine (purine)
Q336. What type of precursor to colon cancer is the worst?
A336. Villous Polyps; (Villous are the Villains)
Q337. Place of Colon CA: signs of anemia: pallor, weakness; possible dull abdominal pain
A337. Right Colon
Q338. Place of Colon CA: pencil-thin stools, rectal bleeding, constipation, vomiting
A338. Left Colon
Q339. What is the next step if you fecal occult blood test is positive?
A339. Colonoscopy
Q340. At what age should annual rectal exams begin?; Fecal occult blood test?; Flexible sigmoidoscopy or colonoscopy?; What if there is a family member with a History of colon cancer?
A340. Annual Rectals: 40 years-old; FOBT: 50 years-old; Sigmoidoscopy / Colonoscopy:beginning at 50 years-old, for every 3-5 years; History of Colon CA: at 40yo or 10 years earlier then the family member's Dx (whichever is earlier)
Q341. Dx: 70-yo woman presents with microcytic anemia, weight loss, and a vague abdominal pain that is not related to food or time of day
A341. Colorectal CA
Q342. Dx lab test findings for Colon CA; (3)
A342. Anemia (iron deficiency);; elevated CEA;; Check LFTs (inc may indicate Mets)
Q343. What type of colon polyp is benign?; Which (2) have malignant potential?
A343. Benign: Tubular; Malignant potential: Villious; Tubulovillous
Q344. What is done if a polyp is found on colonoscopy?; when is the colonoscopy repeated?
A344. perform a polypectomy/Biopsy; repeat colonoscopy: 3 years
Q345. In Endocarditis, which two bugs are assoc with Colon CA?
A345. Strep Bovis;; Clostridium Septicum
Q346. Duke's Classification of Staging and Prognosis for Colon CA; (A-D and 5-year survival percent)
A346. A: Confined to Mucosa and Submucosa - >80%; B: Invasion of Muscularis propria - 60%; C: Local node involvement - 20%; D: Distant Mets - 3%
Q347. First step in Tx for Colon Cancer; Next?; What Dx would lead to Radiation therapy?
A347. 1. Surgical resection (cures 50% in stage A and B);; 2. Chemotherapy;; Radiation only for Rectal involvement
Q348. Drug regimen for Colon Cancer; (2 plus one of 2 more)
A348. 5-FU and Levimasole (stage B and higher); plus: Oxaliplatinum or Irinotecan
Q349. Hereditary Colon CA Syndromes; (4)*; which is the only low-moderate risk (the rest being high risk)?
A349. Family Has Growing Polyps:; Familial Polyposis Coli;; Hereditary Non-polyposis Colon CA;; Gardner's Syndrome;; Peutz-Jeghers Syndrome (low risk)
Q350. Definition: thousands of adenomatous polyps appear throughout the colon by age 25 and cancer hits by 40-yo. What are the genetics?
A350. Familial Polyposis Coli; Autosomal Dominant
Q351. Definition: condition in which 3 or more relatives of a patient and at least one first-degree relative, develops colon cancer at an early age; What are the genetics?; When and How often should a colonoscopy be performed on this individual or his/her offspring?
A351. Hereditary Non-Polyposis Colon CA; Autosomal Dominant; Colonoscopy: Start at age 25; repeat every 1 - 2 years
Q352. Definition: disorder characterized by polyposis coli, supernumerary teeth, osteomas and fibrous displasia of the skull and mandible; What are the genetics?
A352. Gardner's syndrome; Autosomal Dominant
Q353. Definition: multiple polyposis of the small intestine with multiple pigmented melanin macules in the oral mucosa or presents with freckles on lips; What other cancer is it assoc with?
A353. Puetz-Jeghers syndrome; assoc with: GYN Cancer
Q354. Definition: Polyposis with medulloblastoma or glioma
A354. Turcot's syndrome
Q355. MC complaint or presentation of Colon CA
A355. Intermittent Rectal Bleeding
Q356. Order of steps for resuscitation in the general approach to GI bleeds; (6)
A356. 1. Establish IV with (2) large-bore IV caths; 2. Evaluate for Hemodynamic instability (hypotension, tachycardia); 3. Type and cross, CBC, coag study; 4. IV fluid and blood; 5. Vasopressors if BP does not respond to aggressive fluid; 6. GI and Surgical evaluation
Q357. *When do you answer: Capsule Endoscopy?
A357. Procedure of choice for suspected small bowel bleeding not detected in upper or lower endoscopy
Q358. How may UGI bleeds present?; (4)
A358. Hematemesis;; Coffee ground emesis;; Melena;; Hematochezia (BRBPR)
Q359. How may a LGI bleed present?; (2)
A359. Hematochezia (BRBPR);; Melena
Q360. Etiology of UGI bleed; (5)*
A360. Mallory's Vices Gave (her) An Ulcer:; Mallory-Weiss tear;; Varices;; Gastritis;; Arteriovenous Malformation;; Ulcer (peptic)
Q361. Dx tests for UGI or LGI (same tests); (6)
A361. Gastric Lavage;; Rectal exam;; CBC;; Endoscopy;; Bleeding scan;; Arteriography
Q362. Test that detects active bleeding by infusing a radioactive colloid and watching it collect in the GI; When is this the correct answer?
A362. Bleeding Scan; correct: Next step in patient with severe GI bleeding in whom the lower endoscopy is unable to find the source.
Q363. Etiology of LGI bleed; (6)*
A363. Can U Cure Aunt Di's Hemorrhoids?; Cancer or Polyps;; Upper GI bleed (Rule-out);; Colitis;; Angiodysplasia;; Diverticulosis;; Hemorrhoids
Q364. What class (and drug example) of anti-diarrheal agents is contraindicated in diarrhea that is due to infectious agents?; Why?
A364. Opiates (Loperamide); because they promote longer contact time b/t bacteria and intestinal mucosa
Q365. By asking the Quantity of diarrhea, how can it help with the Diff Dx in relation to site of problem?
A365. Small bowel: Large-volume, Watery diarrhea; Large Bowel: Small-volume diarrhea
Q366. Bugs that cause Bloody Diarrhea; (5)*
A366. CASES:; Campylobacter;; Amoeba (E. Histolytica);; Shigella;; E.coli;; Salmonella
Q367. What is acute (<2 weeks) of diarrhea usually due to?
A367. Infectious etiology
Q368. What should the stool be tested for if infectious diarrhea is suspected?; (4); which must be done with 3 different bowel movements over 3 days?
A368. Leukocytes;; Ova and Parasites (over 3 days);; C. Difficile;; Culture
Q369. Bug Dx: patient vomits within 6 hours of eating something with mayonnaise
A369. Staphylococcus
Q370. Bug Dx: patient has vomiting/diarrhea after eating reheated rice from leftover Chinese food
A370. Bacillus Cereus
Q371. Bug Dx: patient has vomiting and severe watery diarrhea after eating shellfish
A371. Vibrio Cholera
Q372. Bug Dx: patient has flatulence and foul-smelling diarrhea after a camping trip; Tx?
A372. Giardia Lamblia; Tx: Metronidazole
Q373. Bug Dx: patient has watery diarrhea following a recent course of Antibiotics; Tx? (2)
A373. C. Difficile; Tx: Oral Metronidazole or Vancomycin
Q374. Bug Dx: causes diarrhea from contaminated water in third- world countries
A374. Vibrio Cholera
Q375. Bug Dx: causes diarrhea and is assoc with Guillian-Barre syndrome
A375. Campylobacter
Q376. Bug Dx: causes diarrhea and is assoc with raw eggs
A376. Salmonella
Q377. Bug Dx: causes diarrhea and is common in AIDS patient
A377. Cryptosporidium
Q378. Basic Tx for all acute diarrhea. (2); If it is due to bacteria, what is added to Tx? (2 possible); If it is Parasitic?
A378. All Acute Diarrhea:; 1. Rehydration and Electrolyte replacement;; 2. Anti-motility agent (AMA only if not infectious diarrhea) Bacteria:; 1. Ciprofloxacin;; 2. Bactrim (TMP-SMX) Parasite: Flagyl (Metronidazole)
Q379. (3) viral causes of Acute Diarrhea
A379. Rotavirus;; Norwalk virus;; CMV
Q380. (5)* Classes for the etiology of Chronic Diarrhea
A380. Something Old Died In Me:; Secretory;; Osmotic;; Decreased transit;; Inflammatory;; Malabsorption
Q381. If fecal pH is < 5.5, what does it suggest the cause of diarrhea is?
A381. Carbohydrate Malabsorption
Q382. *What is a D-Xylose Test?; What (3) diseases make it abnormal?
A382. D-Xylose: Test for chronic diarrhea that helps distinguish b/t malabsorption and Chronic Pancreatitis. Low levels in Urine = problem with small bowel mucosal transport. Abnormal results in:; 1. Celiac Disease; 2. Tropical Sprue; 3. Whipple's Disease
Q383. How is the Osmotic gap determined for diarrhea (equation)?; what do the results indicate?
A383. OG = 290 - 2(Na + K); > 50 mOsm = Osmotic component; < 50 mOsm = Secretory (or other cause)
Q384. What would a 24-hour fasting help distinguish b/t with regards to chronic diarrhea?
A384. Osmotic Diarrhea - resolves with fasting; Secretory Diarrhea - does not resolve with fasting
Q385. diagnostic test for ppl w + fobt
Q386. most common site of distant spread in colorectal cancer
A386. liver
Q387. what type of polyps are considered to have malignant potential
A387. adenomatous polyps (villous > tubular)
Q388. features of familial polyposis syndrome
A388. autosomal dominant; hundreds of adenomatous polyps in colon; colon always involved, duodenum usually (90%) involved
Q389. tx for familial polyposis syndrome
A389. prophylactic colectomy
Q390. clinical features of gardner's syndrome
A390. autosomal recessive; polyps + osteomas, dental abnormalities, benign soft tissue tumors, desmoid tumors, sebaceous cysts; 100% risk of colon ca
Q391. clinical features of turcot's syndrome
A391. autosomal recessive; polyps + cerebellar medulloblastoma or gbm
Q392. peutz-jeghers
A392. single or multiple hamartomas scattered through gi tract (mostly in small bowel and colon); pigmented spots around lips and oral mucosa, genitalia, palmar surfaces; low malignant potential
Q393. complications of peutz-jeghers
A393. intussusception or bleeding
Q394. familial juvenile polyposis coli
A394. rare, small risk for colorectal cancer
Q395. hereditary noNPOlyposis colorectal cancer
A395. no adenomatous polyps; lynch syndrome 1 and 2; early onset colorectal cancer and other cancers
Q396. #1 cause of colon obstruction in adults
A396. colorectal cancer
Q397. most life threatening presentation of colorectal cancer
A397. colonic perforation
Q398. presentation of a right sided colon tumor
A398. obstruction not commonly seen (lumen is wider on right); change in bowel habits is rare; MELENA is most common type of bleed
Q399. presentation of left sided colon tumor
A399. smaller lumen diameter, so can present with obstruction, alternating constipation and diarrhea; narrowing of stools; HEMATOCHEZIA
Q400. which side of colon is melena more common in?; hematochezia?
A400. right; left
Q401. most common presentation of rectal cancer
A401. hematochezia
Q402. when should CEA levels be obtained in colorectal cancer
A402. before surgery
Q403. use of radiation tx in colorectal cancer
A403. used in rectal ca but not in colon ca
Q404. frequency of colonoscopies in patients with history of colorectal cancer
A404. colonoscopy at 1 yr, then q3y
Q405. in addition to colonoscopy, what other f/u is required in patients with colorectal cancer
A405. CT scan of abdomen and pelvic; CXR; do these for up to 5 yrs; check CEA q 3-6 months
Q406. recurrence rate of colorectal cancer
A406. 90% within 3 yrs of surgery
Q407. what types of polyps are associated with UC
A407. pseudopolyps
Q408. pathogenesis of diverticuli
A408. outpouching at area of weakness in colon wall, which is at the site of a bv penetration --> bleeding
Q409. risk factors for diverticulosis
A409. constipation increases intralumenal pressure; family history
Q410. #1 location of diverticuli
A410. sigmoid colon
Q411. test of choice for diverticulosis
A411. barium enema
Q412. tx of diverticulosis
A412. high fiber food to increase stool bulk psyllium
Q413. complications of diverticulosis
A413. painless rectal bleeding; diverticulitis
Q414. complications of diverticulitis
A414. bowel obstruction; fistula; abscess
Q415. how to manage bleeding in diverticulosis
A415. usually stops on its own - no tx for these patients; if it continues, then colonoscopy should be performed to locate site of bleeding, if persistent or recurrent, surgery may be needed
Q416. dx of diverticulitis
A416. ct abdomen and pelvis; abdominal XR to rule out other causes, ileus, obstruction, and perforation
Q417. tx of diverticulitis for first episode
A417. NPO; antibiotics; surgery may be necessary if persists x 3-4 days
Q418. examples of angiodysplasia of the colon
A418. AV malformation; vascular ectasia
Q419. dx of angiodysplasia of the colon
A419. colonoscopy
Q420. tx of angiodysplasia of the colon
A420. colonoscopic coagulation; if bleeding persists, right hemicolectomy (cecum is most common location)
Q421. types of acute mesenteric ischemia; which is most common
A421. arterial embolism *; venous thrombosis (rarest); arterial thrombosis; nonoclusive mesenteric ischemia
Q422. random association with angiodysplasia of the colon
A422. aortic stenosis
Q423. clinical history of patient with mesenteric arterial thrombosis
A423. patients with history of atherosclerotic disease at other sites; acute occlusion occurs over preexisting atherosclerotic disease (acute event can be a decrease in CO or plaque rupture); collateral circulation has usually developed; SYMPTOMS are gradual and less severe than embolic causes
Q424. clinical history of a patient with nonocclusive mesenteric ischemia
A424. splanchnic vasoconstriction secondary to low CO; typically seen in elderly
Q425. overall mortality of all causes of acute mesenteric ischemia
A425. 60%
Q426. presentation of patient with venous thrombosis as a cause for mesenteric ischemia
A426. symptoms may be present for several days or weeks with gradual worsening
Q427. clinical feature of acute mesenteric ischemia
A427. severe abdominal pain disproportionate to physical findings
Q428. complications of acute mesenteric ischemia
A428. peritonitis; sepsis; shock
Q429. dx of acute mesenteric ischemia
A429. mesenteric angiography; plain film of abdomen to rule out other causes
Q430. tx of acute mesenteric ischemia
A430. IVF; broad spectrum antibiotics; papaverine (vasodilator) into superior mesenteric artery during arteriograph to relieve occlusion and vasospasm; direct infusion of thromboloytics in patients with embolism; heparin for venous thrombosis
Q431. signs of intestinal infarction
A431. hypotension, tachycardia, tachypnea, lactic acidosis, fever, change in ms, shock; CHECK LACTATE LEVEL
Q432. causes of chronic mesenteric ischemia
A432. atherosclerotic occlusive disease of celial artery and sma, ima
Q433. symptoms of chronic mesenteric ischemia
A433. abdominal angina (postprandially)
Q434. tx of chronic mesenteric ischemia
A434. surgical revasularization
Q435. tx of ogilvie's syndrome
A435. decompression with gentle enemas or ng suction; if not, colonoscopic decompression; surgical decompression is last resort
Q436. complication of pseudomembranous colitis
A436. toxic megacolon with risk of perforation; amasarca; electrolyte disturbances
Q437. tx of pseudomembranous colitis
A437. metronidazole; (oral vancomycin if metronidazole is contraindicated - infants and pregnancy)
Q438. most common cause of upper GI bleeding
A438. pud (duodenal ulcer, gastric ulcer, gastritis)
Q439. pertinent history in a patient with aorticoenteric fistula
A439. distant history of aortic graft surgery, in a patient with a small GI bleed, involving the duodenum; massive, fatal hemorrhage occurs hours to weeks later
Q440. tx of aortoenteric fistula
A440. endoscopy or surgery
Q441. where is the bleeding from? test to order?; hematemesis
A441. Upper GI; endoscopy
Q442. where is the bleeding from? test to order?; hematochezia
A442. Lower GI; first rule out hemorrhoids; colonoscopy
Q443. where is the bleeding from? test to order?; melena
A443. Upper GI or right side of colon; do endoscopy first, if negative, do colonoscopy
Q444. where is the bleeding from? test to order?; occult blood
A444. Lower GI; colonoscopy; upper endoscopy if colonoscopy is -
Q445. type of pain: vague, dull, poorly localized, usually midline due to bilateral innervation of organs based on embryologic origin
A445. Visceral Pain; (Visceral is Vague); ex: early appendicitis
Q446. type of Pain: sharp, well-localized and involves the peritoneum and is associated with rebound and guarding
A446. Parietal Pain (Parietal is PiNPOint); ex: late appendicitis
Q447. Referred pain: Ureteral obstruction in man
A447. Ipsilateral testicle
Q448. Dx: 45-yo obese woman complains of fever, RUQ pain and nausea that worsens when she eats fatty foods
A448. Cholecystitis
Q449. Diff Dx: Epigastric Pain; GI (3); Pancreatic (2); Aortic (2); Cardiac (3)
A449. Gastritis; Peptic Ulcer; GERD; Acute/Chronic Pancreatitis; Ruptured Aortic Aneurysm; Dissecting Aorta; Angina, MI, Pericarditis
Q450. Diff Dx: RUQ Pain; Hepatobiliary (4); GI (1)
A450. Cholelithiasis; Cholecystitis; Cholangitis; Hepatitis; Peptic Ulcer
Q451. Diff Dx: LUQ Pain; Splenic (5); GI (1)
A451. Spleen trauma; infarction; abscess; rupture; Mononucleosis; Gastric Ulcer
Q452. Diff Dx: RLQ Pain; GI (3)
A452. Small bowel obstruction;; Appendicitis;; Crohn's Disease
Q453. Diff Dx: LLQ Pain; GI (2)
A453. Inflammatory Bowel Disease;; Diverticulitis
Q454. Diff Dx: Flank Pain; GU (5)
A454. NET PP:; Nephrolithiasis;; Epididymitis;; Testicular Torsion;; Pyelonephritis;; Prostatitis
Q455. Diff Dx Pain: Adnexal (lower abdominal) Pain; (6)
A455. PET SOCk:; PID;; Ectopic Pregnancy;; Tubo-ovarian abscess;; Salpingitis;; Ovarian torsion;; Cystitis
Q456. Dx: 26-yo woman has severe LLQ pain, vaginal bleeding and light-headedness. Last menstrual period was 6 weeks ago
A456. Ectopic Pregnancy
Q457. Diff Dx: Pain Anywhere in Abdomen; (4)
A457. Strangulated hernia;; Large Bowel Obstruction;; Sigmoid Volvulus;; Mesenteric Ischemia
Q458. Dx: 28-yo woman presents with diffuse abdominal pain, nausea, and confusion. She is not pregnant but takes a stained-glass class.
A458. Lead poisoning
Q459. Diff Dx: Abdominal wall Pain; (2)
A459. Hernia; Rectus sheath hematoma
Q460. Diff Dx: Metabolic/genetic-related Abdominal pain; (4)
A460. HyperC;; Acute Intermittent Porphyria;; DKA;; Sickle cell
Q461. Diff Dx: Viral-related Abdominal Pain; (3)
A461. Herpes Zoster;; Mononucleosis;; HIV
Q462. Diff Dx: Toxin-related Abdominal Pain; (2)
A462. Heavy Metal poisoning; Black Widow Spider venom
Q463. (3) vascular causes of abdominal pain to always consider in the elderly
A463. MAM:; Mesenteric Ischemia;; AAA;; MI
Q464. Diff Dx of an emergency patient with absent bowel sounds (3) or high-pitched sounds (1)
A464. Absent: Pancreatitis;; Ischemia;; Acute Abdomen; High-pitched: Obstruction
Q465. 63-yo obese man complains of pain in his "kidney" for 3 days. He has History of MI x 2 and no back tenderness.
A465. AAA
Q466. Dx: hypotension; abdominal or back pain; pulsatile mass in abdomen; History of vascular disease or atherosclerosis
A466. AAA
Q467. (3) Dx tests for AAA
A467. Angiogram (gold standard); MRI or CT with contrast
Q468. Dx: 72-yo man with History of A-fib, on digoxin and complains of severe abdominal pain out of proportion to the exam
A468. Acute Mesenteric Ischemia
Q469. 72-yo woman with History of MI complains of gnawing abdominal pain after eating. She lost 15 pounds in the past month.
A469. Chronic Mesenteric Ischemia
Q470. Cause of Acute (2) vs. Chronic Mesenteric Ischemia
A470. Acute: Emboli (A-fib); Hypercoagulability; Chronic: Atherosclerosis
Q471. (2) possible lab signs with Mesenteric Ischemia
A471. Increased Lactate; Metabolic Acidosis
Q472. Gold standard test for Mesenteric Ischemia; (2) others
A472. Gold standard: Angiogram; others: Spiral CT with contrast, MRI
Q473. First step for Mesenteric Ischemia; Next?
A473. First: Maintain tissue perfusion with IV fluids until... Surgical bypass
Q474. Cholelithiasis -; Colic results from what?; Risk factors
A474. Colic from transient cystic duct blockage. Risk factors - female, fat, forty, fertile.
Q475. Cholelithiasis; 3 types
A475. 1. Cholesterol (80%) - originate from gallbladder; risk factors: obesity, rapid weight loss, Crohn's, CF, estrogens, Native Americans 2. Pigment - originate from common bile duct, calcium bilirubinate; risk factors: chronic hemolysis, biliary infections, alcohol abuse, cirrhosis 3. Mixed
Q476. Cholelithiasis - History/PE
A476. Postprandial abdominal pain; RUQ pain; radiates to rt. subscapular or epigastrium (can be asymptomatic); n/v; fatty food intolerance; dyspepsia; flatus; RUQ tenderness
Q477. Cholelithiasis - Diagnosis
A477. not XR - only 15% radiopaque; RUQ US
Q478. Cholelithiasis - Tx
A478. Cholecystectomy with Symptoms; ERCP - common bile duct stones; dietary modification; UDCA - if don't want surgery, effective in noncalcified cholesterol stones < 5 mm
Q479. Cholelithasis - Complications
A479. recurrent biliary colic; acute cholecystitis; choledocholithiasis; acute cholangitis; gallstone ileus; gallstone pancreatitis; carcinoma of the gallbladder
Q480. Acute Cholecystitis; Results from what; Leads to what
A480. Prolonged obstruction of cystic duct (usually stone); Distention, inflammation, infection, gangrenous, acalculous; Acalculous - in absence of cholelithiasis in TPN, trauma, burn patients.
Q481. Acute Cholecystitis; History/PE
A481. RUQ pain; n/v; low-grade fever; Murphy's sign
Q482. Acute Cholecystitis; Dx
A482. US; HIDA scan; CBC; amylase, lipase; bilirubin; LFT
Q483. Acute Cholecystitis; Tx
A483. IV Antibiotics; IV fluids; replete electrolytes; early cholecystectomy; preop ERCP; intraop cholangiogram
Q484. Acute Cholecystitis; Complications
A484. gangrene; abscess; perforation; empyema; sepsis; gallstone ileus; fistulization
Q485. Choledocholithiasis - Results from what
A485. gallstones in the COMMON BILIARY DUCT
Q486. Choledocholithiasis - History/PE
A486. biliary pain; jaundice; colic; fever; pancreatitis
Q487. Choledocholithiasis - Dx
A487. Increased alkaline phosphatase and total bili
Q488. Choledocholithiasis - Tx
A488. ERCP with stone extraction and sphincterotomy; cholecystectomy
Q489. Acute Cholangitis; Results from what; Leads to what
A489. Acute bacterial infection of biliary tree - from primary sclerosing cholangitis or obstruction (gallstones) as obstruction persists (usu from choledocholelith.); increased in intraluminal pressure --> reflux of bacteria to systemic circulation; Charcot's triad => Reynolds' pentad
Q490. Acute Cholangitis; Bacteria
A490. E Coli; Pseudomonas; Enterobacter
Q491. Acute Cholangitis; History/PE
A491. Charcot's triad; Reynold's pentad
Q492. Acute Cholangitis; What is Reynold's pentad and what does it suggest
A492. RUQ pain; jaundice; fever/chills; shock; altered mental status; suggests sepsis
Q493. Acute Cholangitis; Dx
A493. leukocytosis; increased alkaline phosphatase and bili; BC (to rule out sepsis); US or CT - may be useful; ERCP
Q494. Acute Cholangitis; Tx
A494. ICU; IV Antibiotics; IV hydration; bile duct decompression - open surgical, percutan transhepatic drain or ERCP sphincterotomy
Q495. Diarrhea; What is it; Risk factors
A495. > 200 gm feces/day, change in stool consistency; viral/bact. GI infection; systemic infection; sick contacts; immunosuppression; recent Antibiotics use; recent travel
Q496. Diarrhea - What are the types (1)
A496. Acute - < 2 wks of Symptom, infectious and self-limited, 2nd MCC - drug side effect chronic - > 2-3 wks of Symptom, disrupted secretion, malabsorption, altered motility; MCC in adults - lactase def. pediatric - usually rotavirus; can also divide as infectious, secretory, osmotic
Q497. What are Infectious Diarrhea
A497. - enterotoxigenic: E. coli (traveller's diarrhea); enteroinvasive: bloody diarrhea & fever; campylobacter -MC bacteria to cause diarrhea, MCC of reactive arthritis; shigella - transferred by food & water, found in daycare; salmonella - raw eggs & dairy; V. vulnificus: severe if have liver dis. Yersinia: abdominal pain, joint pain, rash, may resemble appendicitis; E. coli O157:H7, HUS; viral: MCC of infectious diarrhea
Q498. What are secretory & osmotic diarrhea
A498. Secretory: diarrhea > 1L; carcinoid syndrome; Zollinger-Ellison syndrome; VIPoma; phenolphthalein (laxative) osmotic - > 50 osmol/kg osmolality; lactose, fructose, sorbitol; MCC - lactase def.
Q499. Diarrhea - Dx
A499. - stool electrolytes - secretory vs. osmotic; fecal leukocytes – enteroinvasive, IBD; methylene blue - checks for WBC; stool Cx, O&P; giardia - string test & stool giardia Ag; cryptosporidia - modified AFB stain; NaOH - turns stool red if phenolphthalein use; colonoscopy or Biopsy
Q500. Diarrhea - Tx
A500. infectious - self-limited; mild - oral fluids & electrolytes; severe - IV fluids & oral Antibiotics, initial empiric- ciprofloxacin; invasive - TMP-SMX or ciprofloxacin; giardia - metro; c. diff - metro; campylobacter - erythromycin; scombroid - antihistamine; cryptosporidium - control underlying HIV with antiretrovirals
Q501. IBS - What is it
A501. abdominal pain; changes in bowel habits; increased with stress; relieved by BM; 1/2 of patients. have comorbid psych disorders
Q502. IBS - History/PE
A502. Symptoms for at least 3 mos. usually absent at night; abdominal pain; change in bowel habits; abdominal distention; stools with mucus; relief of pain with a BM
Q503. IBS - Dx
A503. Dx of exclusion; rule out - lactose intolerance, IBD, hypo- or hyperthyroidism; always flexible sigmoidoscopy if patient > 40 y/o
Q504. IBS - Tx
A504. fiber supplements; TCAs, antidiarrheals, antispasmodics; tegaserod - constipation-predominant.
A505. cramping - crescendo-descrendo every 5-10 min. vomiting: bilious – early, feculent - distal; partial obstruction - flatus, no stool; complete obstruction - no flatus or stool; T/D (accumulation of gas and fluid); prior surgical scars; high-pitched tinkles; peristaltic rushes; later, peristalsis disappears
A506. adhesions from prior abdom; surgery (60%); hernias; neoplasms; intussusception; gallstone ileus; stricture from IBD; volvulus; CF
A507. - leukocytosis - if strangulation; dehydration (vomiting); metab. alkalosis (vomiting); lactic acidosis - if necrotic bowel; need emergency surgery; radiopaque in cecum - gallstone ileus; XR - stepladder pattern; air-fluid levels
A508. partial -, NPO, NG suction, IV hydration, correct electrolytes, Foley; surgery if complete obstruction, necrotic bowel, Symptom > 3D with no resolution; exploratory laparotomy
Q509. Ileus; what is it; Risk factors
A509. temp arrest of intestinal peristalsis Risk factors; recent surgery/GI procedures; immobility; hypokalemia; hypothyroidism; DM; meds (anticholinergics, opioids); After every abdominal operation for 24-48 hours Due to - sympathetic overeaction, bowel manipulation, K+ depletion (preop vomiting), peritoneal irritation from blood or peritonitis, atony of colon & stomach
Q510. Ileus - History/PE
A510. abdominal discomfort; n/v; no flatus or BM; abdominal distention; decreased or no bowel sounds; rectal exam if elderly to rule out fecal impaction
Q511. Ileus - Dx
A511. AXR - distended loops, air-fluid levels (upright); gastrografin - rule out partial obstruction; CT - rule out neoplasm
Q512. Ileus - Tx
A512. decrease meds that reduce; bowel motility; decrease/discont. oral feeds; NG suction; parenteral feeds; replete electrolytes
Q513. Carcinoid Syndrome - What causes it
A513. Carcinoid tumors; neuroendrocrine cells; enterochromaffin cells; usually from ileum, appendix
Q514. Carcinoid Syndrome - What do they secrete
A514. serotonin; tryptophan; tachykinin (substance P); ACTH, gastrin; secrete high levels => depletion of tryptophan => pellagra (niacin def.); levels do not get metabolized by liver due to liver mets; MC found incidentally during appendectomy
Q515. Carcinoid Syndrome - History/PE
A515. flushing; diarrhea; wheezing; right-sided valvular disease
Q516. Carcinoid Syndrome - Dx
A516. high urine levels of 5-HIAA - diagnostic; chest and abdominal CT
Q517. Carcinoid Syndrome - Tx
A517. octreotide (for symptoms); surgery
Q518. Diverticular Disease - What is it
A518. Outpouching of mucosa and submucosa that herniate in areas of high intraluminal pressure; common in sigmoid colon; MCC of acute lower GI bleeding in patients. > 40
Q519. Diverticular Disease - Risk factors
A519. low-fiber and high-fat diet; advanced age; connective tissue disorders (Ehlers-Danlos, Marfans)
Q520. Diverticular Disease - History/PE
A520. LLQ abdominal pain; abnormal bowel habits; bleeding painless and sudden; usually hematochezia; Symptom of anemia
Q521. Diverticulitis - PE
A521. LLQ pain; fever; n/v; perforation - complication
Q522. Diverticular Disease - Dx
A522. CBC (leukocytosis); AXR; colonoscopy or barium enema; avoid invasive techniques in early diverticulitis - risk of perforation; CT - check for abscess, free air after acute episode if >50 y/o; flexible sigmoidoscopy (rule out perforating colon cancer)
Q523. Diverticular Disease - Tx for uncomplicated disease
A523. high-fiber diet
Q524. Diverticular Disease - Tx for bleeding
A524. bleeding usually stops spontaneously; transfuse and hydrate; if bleeding doesn't stop - angiography with embolization; surgery
Q525. Diverticular Disease - Tx for diverticulitis
A525. NPO; NGT; metro and fluoroquinolone or cephalosporin if perforation - resect; anastomosis or temp colostomy
A526. constipation; cramping abdominal pain; n/v; feculent vomiting; tenderness; significant distention; tympany; high-pitched tinkly BS; later, no BS
A527. colon cancer; benign tumors; diverticulitis; volvulus; fecal impaction; assume colon ca until proven otherwise
A528. tx obstruction with - gastrograffin enema; colonoscopy; rectal tube; surgery usually needed; tx underlying cause
Q529. Colon and Rectal Cancer - History/PE
A529. presents with symptom after long period of silent growth; abdominal pain and symptom based on location; right-sided lesion - stool is liquid, ca can get large before symptom, lesions commonly ulcerate => chronic blood loss, can bleed intermittently; left-sided lesion - stool more concentrated, apple-core lesions; rectal – BRBPR, rectal pain, can coexist with hemorrhoids, so rule out in all patients with rectal bleeding
Q530. Colon and Rectal Cancer - Dx
A530. CBC (anemia); guiac; sigmoidoscopy - left; colonoscopy/barium enema - right; US (how much invaded); CT/MRI (to stage); CXR, LFT, abdominal CT - metas
Q531. Colon and Rectal Cancer - How does mets spread
A531. direct; hematogenous - liver primary; lymphatic -pelvic lymph nodes
Q532. Colon and Rectal Cancer - Tx
A532. bowel prep - Golytely, Antibiotics; colon - resect colon, lymph, mesentery, anastomosis; rectum - if < 10cm from anal verge, abdominoperineal resection, rectum and anus resected, permanent colostomy; if > 10cm, low anterior resection, anastomosis between colon & rectum; wide local excise - low stage; also chemo - colon with nodes; also radiation - rectum; Followup with CEA, colonoscopy, LFTs, CXR, abdominal CT Duke classification; surgery - stages A&B; stages C1 & C2 - surgery and chemo, 5-FU and leucovorin
Q533. Colon and Rectal Cancer - Risk factors
A533. age; hereditary - FAP, Gardner's, HNPCC; APC gene, p54; Strep bovis bacteremia; family History; UC; adenomatous polyps; past History of colorectal ca; high-fat, low-fiber diet
Q534. Colon and Rectal Cancer - Screening
A534. DRE yearly > 50 y/o; guaiac yearly > 50 y/o; colonoscopy every 10 yrs > 50 or sigmoidoscopy every 3-5 > 50 or colonoscopy every 10 yrs > 40 with family history of ca/polyp or 10 yrs prior to age of dx of youngest family member with colorectal ca
Q535. Dysphagia - What is it
A535. Difficulty swallowing due to abnormalities of the oropharynx or esophagus.
Q536. Odynophagia - What is it
A536. Pain with swallowing due to abnormalities of the oropharynx or esophagus.
Q537. Dysphagia; Etiologic factors; (Caused by)
A537. Achalasia; peptic stricture; esophageal webs or rings; carcinoma; Scleroderma; spastic motility disorders; Sjogren's; meds; radiation injury
Q538. Dysphagia - PE
A538. examine for masses (goiter, tumor); examine for anatomical defects
Q539. Dysphagia - Dx
A539. oropharyngeal - cine-esophagram; esophageal - barium swallow then endoscopy, manometry, pH monitoring; odynophagia - upper endoscopy
Q540. Dysphagia; Tx; Tx for Achalasia
A540. Etiology dependent; achalasia - botulinum toxin, calcium channel blockers, balloon dilatation; all 3 temporizing measures; esophageal myotomy for long-term tx
Q541. Esophageal Cancer - What is it
A541. squamous cell ca – midesophagus from smoking and alcohol, can develop fistulas to bronchi; adenocarcinoma - barrett's esophagus, columnar metaplasia replaces squamous distal esophagus, secondary to chronic GERD
Q542. Esophageal Cancer - Risk factors
A542. achalasia; barrett's; cigarettes; etoh; webs; male gender
Q543. Esophageal Cancer - History/PE
A543. progressive dysphagia - first solids then liquids; weight loss; GERD; GI bleeding; vomiting
Q544. Esophageal Cancer - Dx
A544. barium swallow 1st; EGD; biopsy – confirm; (MRI/CT - evaluate for mets)
Q545. Esophageal Cancer - Tx
A545. surgery if local; metastatic - cisplatin, 5-FU & radiation; chemoradiation - poor prognosis; esophageal stent - palliation
Q546. GERD - What is it
A546. transient LES relaxation from; incompetent LES; gastroparesis; hiatal hernia
Q547. GERD - Risk factors
A547. increased intra-abdominal pressure (obesity, pregnancy); scleroderma; alcohol; caffeine; nicotine; chocolate; fatty foods
Q548. GERD - History/PE
A548. heartburn 30-90 min post meal; pain worse with reclining; pain better with antacids,; sitting, standing; sour taste ("water brash")
Q549. GERD - Dx
A549. Based largely on History; confirm - respond to Tx; 24hr pH monitor- gold standard; Bernstein test - confirms origin of pain
Q550. GERD - Tx
A550. - lifestyle - weight loss, head-of-bed elevation, stop eating 3 hrs before bed, eat small meals; monitor for barretts/adenoca, serial EGD, Biopsy; antacids - if intermittent; H2 blockers and PPI; surgery - nissen fundoplication
Q551. GERD - Complications
A551. esophageal ulceration; esophageal stricture; aspiration of gastric content; upper GI bleeding; Barrett's - when to do EGD, no dysplasia - every 2-5 yrs. low-grade - every 3-6 mos. high-grade - resection
Q552. Hiatal Hernia - What are types
A552. sliding - gastroesophageal junction and part of stomach above diaphragm due to weakening of anchors of ge junction to diaphragm, longitudinal contractions of diaphragm increased intra-abdominal pressure; paraesophageal - ge junction below diaphragm, part of fundus herniates
Q553. Hiatal Hernia - History/PE
A553. May be asymptomatic; with sliding, may have GERD
Q554. Hiatal Hernia - Dx
A554. CXR (incidental finding); barium swallow; EGD
Q555. Hiatal Hernia - Tx
A555. sliding - lifestyle changes; paraesoph - gastropexy
Q556. Gastritis - What are types
A556. Erosive (acute) - rapidly developing conditions that erode mucosa, NSAIDs, alcohol, H pylori, stress from severe illness (burns, CNS injury); hemorrhagic gastritis; alkaline gastritis; reflux gastritis chronic; type A - (10%), autoab to parietal cells, pernicious anemia, achlorhydria, increased risk of gastric ca. fundus, G cells in antrum, G cells make gastrin, gastrin stim acid secretion => hypergastrinemia; type B - (90%), H pylori, increased risk of gastric ca, antrum
Q557. Gastritis - History/PE
A557. may be asymptomatic; n/v; indigestion; hematemesis; melena
Q558. Gastritis - Dx
A558. Upper endoscopy; Type B - must confirm H. pylori, antral Biopsy - gold standard, CLO test, urease breath test, serum IgG – ELISA to confirm or rule out; only shows exposure (H pylori stool Ag)
Q559. Gastritis - Tx
A559. Erosive - same as for PUD; type A - need B12 for life; type B - must eradicate H. py; Decreased offending agents; antacids; sucralfate; H2 blockers; PPIs; triple therapy to tx H pylori infection: clarithromycin, amoxicillin (or metro), PPI; quadruple therapy: bismuth, metro, tetracycline, PPI or H2 blocker
Q560. Gastric Ca - What are the types
A560. 2 types of adenocarcinoma; intestinal: metaplasia of mucosa by intestinal-type cells, ulcerates, pyloric antrum & lesser curvature, high in Japan, risk factors - diet high in nitrites, salt, low veggies, H pylori, chronic gastritis; diffuse - younger patients, develop throughout stomach, linitis plastica - poorer prognosis
Q561. Gastric Ca - History/PE
A561. advanced cases:; abdominal pain; early satiety; weight loss; 5-yr survival < 10%; mets - Virchow's node, Krukenberg's tumor, Sister Mary Joseph nodule
Q562. Gastric Ca - Dx
A562. early - asymp, superficial,; surgically curable; endoscopy
Q563. Gastric Ca - Tx
A563. must have early detection and removal of tumor
Q564. PUD - What are types
A564. Gastric: pain greater with meals, weight loss, H pylori 70%, NSAIDs decreased mucosal protection; duodenal: pain init. decreased with food or antacids, worsens in 2-3 hrs, can radiate to back, nocturnal pain, 100% H pylori, increased acid secretion
Q565. PUD - Risk factors
A565. duodenal - O blood type, men, MEN I, other risk factors – corticosteroids, NSAIDs, alcohol, tobacco, Curling ulcers, Cushing ulcers; corrosives – acids, strong alkali (lye, NaOH)
Q566. PUD - History/PE
A566. nausea; hematemesis; coffee-ground emesis; melena or hematochezia; epigastric tenderness; if acute perforation - rebound tenderness, guarding; NSAID-associated -, GI hemorrhage & perforation; gastric - n/v, don't improve with antacids & H2-blockers; duodenal - no n/v, wake up in middle of night
Q567. PUD - Dx
A567. Upper endoscopy with Biopsy or barium swallow; then must test for H pylori - invasive: culture, histology, urease; noninvasive: urease breath test, serum IgG, stool Ag test
Q568. PUD - Tx
A568. For H. pylori - 2 wks of combination Tx; 2 Antibiotics and bismuth, H2 blocker or PPI: BMT (bismuth, metro and tetracycline); Prevpac (2 Antibiotics & PPI) - prepacked; Helidac (2 Antibiotics & bismuth) - prepacked; for NSAID-induced - H2 blocker or PPI; misoprostol - for prevention
Q569. PUD - Complications
A569. "HOPI"; Hemorrhage - posterior ulcers erode into gastroduodenal artery; obstruction (gastric outlet); perforation - anterior ulcer; intractable pain; long-term effects of H. pylori; PUD; MALT; chronic superficial gastritis; chronic atrophic gastritis => cancer
Q570. ZE Syndrome - What is it
A570. Gastrin-producing tumors; mainly in head of pancreas; can also be in duodenum, stomach or spleen; 60% are malignant => oversecretion of gastrin => high levels of HCl (from the parietal cells) => ulcers in stomach, duoden. associated with MEN I
Q571. ZE Syndrome - History/PE
A571. Gnawing, burning abdominal pain; n/v; diarrhea; weakness; GI bleeding; most common presentation - PUD & diarrhea or steatorrhea; if hypercalcemia - associated with MEN I
Q572. ZE Syndrome - Dx
A572. measure serum gastrin - increased gastrin levels; stop PPIs before testing; abnormal IV secretin confirms
Q573. ZE Syndrome - Tx
A573. Surgical resection if mets at presentation; (30-50%) - PPIs
Q574. Upper GI Bleeding - History/PE
A574. hematemesis - bright red or coffee-brown, melena; possible iron def. anemia; increased BUN; depleted volume status – tachy, light-headedness, orthostatic hypotension
Q575. Upper GI Bleeding - Dx
A575. NGT and lavage; endoscopy - 1st test; clinical History
Q576. Upper GI Bleeding - Common Causes
A576. gastritis; PUD; Mallory-Weiss tear; esophageal varices; vascular abnormalities; neoplasm; esophagitis; gastric erosions
Q577. Upper GI Bleeding - Initial Tx
A577. protect airway (intubation); IV fluids; transfusion
Q578. Upper GI Bleeding - Long-term management
A578. tx underlying cause; PUD - IV PPI; endoscopic tx for varices - bipolar electrocoagulation, injection therapy, octreotide, sclerotherapy, band ligation
Q579. Lower GI Bleeding - History/PE
A579. hematochezia > melena
Q580. Lower GI Bleeding - Dx
A580. anoscopy,; flexible sigmoidoscopy or colonoscopy; bleeding scan; NG lavage negative, rule out upper GI bleed - if pos. stool and neg. colonoscopy
Q581. Lower GI Bleeding - Common Causes
A581. diverticulosis- MCC in elderly; hemorrhoids - MCC in young; angiodysplasia (AVM); neoplasm; IBD; anorectal disease; mesenteric ischemia; Meckel's; infectious
Q582. Lower GI Bleeding - Initial Tx
A582. protect airway (intubation); IV fluids; transfusion
Q583. Lower GI Bleeding - Long-term management
A583. endoscopic therapy: bipolar electrocoagulation, injection therapy; angiography; surgery
Q584. ULCERATIVE COLITIS; Prevalence; Site of involvement
A584. Prevalence higher than Crohn's; bimodal; starts at rectum then upwards; continuous mucosa and submucosa; granular mucosa; pseudopolyps
A585. bloody diarrhea; pus; lower abdominal cramps
Q586. ULCERATIVE COLITIS - Extraintestinal manifestations
A586. pyoderma gangrenosum; primary sclerosing cholangitis; colorectal ca; toxic megacolon; aphthous stomatitis; arthritis; uveitis; erythema nodosum
A587. CBC; AXR; stool cultures; O&P; stool assay for C. difficile; colonoscopy; Biopsy - definitive Dx
A588. sulfasalazine; 5-ASA (mesalamine); corticosteroids; immunosuppressants; total colectomy
Q589. Crohn's; Distribution; Site of involvement
A589. Bimodal; any portion of GI tract; usually terminal ileum,; small intestine and colon; cobblestone (skip) lesions; transmural
Q590. Crohn's - History/PE
A590. watery diarrhea (most common); (bloody diarrhea only if rectum involved); abdominal pain; fistulas beteween bowel & bladder or bowel & skin; noncaseating granulomas
Q591. Crohn's - Extraintestinal manifestations
A591. pyoderma gangrenosum; primary sclerosing cholangitis; toxic megacolon; aphthous stomatitis; arthritis; uveitis; erythema nodosum; *nephrolithiasis*
Q592. Crohn's - Dx
A592. CBC; AXR; stool culture; O&P; stool assay for C. difficile; colonoscopy; Biopsy - definitive Dx
Q593. Crohn's - Tx
A593. mesalamine; sulfasalazine not as effective; corticosteroids; immunosuppressants - 6-mercaptopurine, azathioprine; infliximab; metro - for fistulas; resection; may recur anywhere in GI tract (after resection)
Q594. Inguinal Hernia - Types
A594. Indirect – congenital, patent processus vaginalis, internal inguinal ring => external inguinal ring => scrotum, Most common type for both genders; Direct - through floor of Hesselbach's triangle, goes direct thru abdominal wall in aponeurosis of ext. obliq, acquired defect in transversalis fascia, increased with age
Q595. Inguinal Hernia - What is Hesselbach's triangle
A595. inferior epigastric artery; inguinal ligament; rectus abdominis
Q596. Inguinal Hernia - Tx
A596. Surgery; Direct - also correct defect in transversalis fascia; Indirect - ligate hernia sac, reduce size of internal inguinal ring
Q597. Portal Hypertension - Definition
A597. Portal vein pressure > 5 mmHg greater than the pressure in the IVC
Q598. Portal Hypertension - Causes
A598. Presinusoidal - splenic or portal vein thrombosis, schistosomiasis, granulomatous disease; Sinusoidal – cirrhosis, granulomatous disease; Postsinusoidal – RHF, constrictive pericarditis, Budd-Chiari syndrome, hepatic vein thrombosis
Q599. Budd-Chiari Syndrome - Definition
A599. thrombotic occlusion of IVC or hepatic vein; centrilobular congestion and necrosis => congestive liver disease (hepatomegaly, ascites, abdominal pain, liver failure); from PCV, pregnancy & hepatocellular ca
Q600. Portal Hypertension - History/PE
A600. History – jaundice, ascites, esophageal varices, hemorrhoids, caput medusa, spontaneous bacterial peritonitis, hepatic encephalopathy, renal dysfunction; PE - icteric sclerae, abdominal fluid wave, shifting dullness, splenomegaly, easy bruising, spider angioma, caput medusa, palmar erythema, gynecomastia, testicular atophy
Q601. Portal Hypertension - Dx
A601. LFTs; alkaline phosphatase; bilirubin; albumin; PT/PTT; serum ferritin; ceruloplasmin; a1-antitrypsin; US; increased indirect hepatic vein wedge pressure; SAAG
Q602. Portal Hypertension; What is SAAG; SAAG > 1.1; SAAG < 1.1
A602. serum-ascites albumin gradient: serum albumin-ascitic albumin; SAAG > 1.1: portal HTN - increased pressure in portal v., chronic liver dis., hepatic mets; SAAG < 1.1: noNPOrtal HTN - nephrotic syndrome, TB, malignancy
Q603. Portal Hypertension - Tx for ascites
A603. restrict Na; diuretics; rule out infection & neoplasms; paracentesis - to get SAAG, CBC, cultures; tx underlying liver disease
Q604. Portal Hypertension; Tx for spontaneous; bacterial peritonitis
A604. Indolent infection of ascitic fluid; pos. if > 250 PMNs/ml or > 500 WBC, Culture and gram stain usually neg., IV 3rd gen. cephalosporin (covers Enterococcus, E. Coli or Klebsiella)
Q605. Portal Hypertension - Tx for hepatorenal syndrome
A605. Dx of exclusion; Hard to tx; Often requires dialysis
Q606. Portal Hypertension - Tx for hepatic encephalopathy
A606. Decreased protein consumption; lactulose; metronidazole
Q607. Portal Hypertension - Tx for esophageal varices
A607. Monitor for GI bleeding; B blockers; band ligation; sclerotherapy; or portocaval shunt
Q608. Hepatocellular Ca - Risk factors for primary
A608. US - cirrhosis; chronic HBV or HCV; worldwide - HBV, HCV, aflatoxin
Q609. Hepatocellular Ca - History/PE
A609. RUQ tenderness; abdominal distention; hepatomegaly; signs of chronic liver dis. – jaundice, easy bruisability, coagulopathy, nodular cirrhotic liver
Q610. Hepatocellular Ca - Dx
A610. US; CT; increased LFTs; significantly increased AFP; Biopsy - definitive Dx
Q611. Hepatocellular Ca - Tx
A611. early detection – resection or orthotopic liver transplant; neoadjuvant therapy - chemo and radiation to shrink large tumor before surgery; serial AFP - monitor recurrence
Q612. Hemochromatosis - What is it
A612. increased in int. iron absorption => too much deposited, accums in skin, pancreas, liver, heart, joints, kidney, pituitary, gonads, adrenals; primary - auto recessive; secondary - chronic transfusions, alcoholics
Q613. Hemochromatosis - History/PE
A613. DM; hypogonadism; arthritis; CHF; restrictive cardiomyopathy; cirrhosis; adrenal insufficiency; hypothyroidism, hypoparathyr. abdominal pain
Q614. Hemochromatosis - Dx
A614. Increased serum iron; increased % iron saturation; increased ferritin; decreased serum transferrin; fasting transferrin saturation > 45%; glucose intolerance; increased AST; increased alkaline phosphatase; liver Biopsy; MRI; C282Y mutation; hepatic iron index > 2.0
Q615. Hemochromatosis - Tx
A615. weekly phlebotomy (1-2 yrs.), then maintenance phlebotomy, every 2-4 months; deferoxamine (maintenance); liver transplant cures
Q616. Hemochromatosis - Complications
A616. cirrhosis; hepatocellular ca; cardiomegaly; CHF; DM; impotence; arthropathy; hypopituitarism
Q617. Wilson's Disease - What is it
A617. Hepatolenticular degeneration; Decreased synthesis of ceruloplasmin => too much copper deposited in liver, brain, cornea; auto recessive (chrom 13); usually presents 15-25 y/o
Q618. Wilson's Disease - History
A618. ABCD; asterixis; basal ganglia degenerates; ceruloplasmin decreased; copper deposited; cirrhosis => hepatocellular ca; choreiform movements (tremor); corneal deposits; dementia; 1st sign - neuro or psych; kayser-fleischer rings always accompany neuro or psych
Q619. Wilson's Disease - PE
A619. Kayser-Fleischer rings - copper in Descemet's membrane; jaundice; hepatomegaly; asterixis; choreiform movements
Q620. Wilson's Disease - Dx
A620. decreased serum ceruloplasmin; increased urinary copper excretion; elevated hepatic copper
Q621. Wilson's Disease - Tx
A621. dietary copper restriction; no shellfish, liver, legume; penicillamine (urine excretes); oral zinc (fecal excretion); cured by liver transplant
Q622. Acute Pancreatitis - What is it
A622. Leakage of pancreatic enzymes into pancreatic and peripancreatic tissue.
Q623. Acute Pancreatitis - Risk factors
A623. GET SMASHeD; gallstones; ethanol; trauma; steroids; mumps; autoimmune dis. scorpion sting; hyperlipidemia; hypercalcemia; drugs (thiazide)
Q624. Acute Pancreatitis - History/PE
A624. Severe epigastric pain; radiates to the back; cullen's (periumbilical); grey-turner (flank)
Q625. Acute Pancreatitis - Dx
A625. Increased amylase - but amylase can read normal if hypertriglyceridemia; increased lipase - more specific; decreased calcium (fat necrosis); "sentinel loop" on AXR; "colon cutoff" on AXR; US or CT - enlarged pancreas, pseudocysts, abscess, hemorrhage, necrosis
Q626. Acute Pancreatitis - Tx
A626. IV fluids; electolyte replacement; analgesia; NPO; NG suction; nutritional support; O2; if necrotizing - IV Antibiotics, respiratory support, surgical debridement; ERCP - if stone in COMMON BILIARY DUCT; debridement - if necrosis; CT-guided drainage – abscess, pseudocyst > 5cm lasts > 1 mo.
Q627. Acute Pancreatitis - Complications
A627. pseudocyst; fistulas; hypocalcemia; renal failure; pleural effusion; sepsis; chronic pancreatitis; splenic vein thrombosis; mortality - Ranson's criteria
Q628. Acute Pancreatitis - Ranson's Criteria
A628. GA LAW - On Admission:; Glucose > 200 mg/dl; Age > 55 yrs. LDH > 350 IU/L; AST > 250 IU/dl; WBC > 16,000/ml C HOBBS - After 48 hours:; Ca2+ < 8.0 mg/dl; Hct decreased by > 10%; O2 PaO2 < 60 mmHg; Base excess > 4 mEq/l; BUN increased > 5 mg/dl; Sequestered fluid > 6L; Mortality risk - 20% with 3-4 signs, 40% with 5-6 signs, 100% with > 7 signs
Q629. Chronic Pancreatitis - What is it
A629. recurrent attacks of acute => irreversible destruction => pancreatic dysfunction
Q630. Chronic Pancreatitis - Risk factors
A630. alcoholism (90%); gallstones; hyperparathyroidism; idiopathic; congenital - pancreas divisum, CF
Q631. Chronic Pancreatitis - History/PE
A631. recurrent episodes of :; persistent epigastric pain; steatorrhea; weight loss; nausea; diabetes
Q632. Chronic Pancreatitis - Dx
A632. Abdominal XR - calcifications; low trypsin; amylase and lipase - normal; secretin stimulation test - most sensitive; glycosuria; mild ileus on AXR and CT ("chain of lakes")
Q633. Chronic Pancreatitis - Tx
A633. Pancreatic enzymes replaced; med-chain triglycerides in diet; decreased fat intake; vitamins; analgesics; Puestow procedure; stop alcohol; celiac nerve block; surgery for -, intractable pain, structural causes
Q634. Chronic Pancreatitis - Complications
A634. chronic pain; pancreatic cancer
Q635. Pancreatic Cancer - What is it
A635. pancreatic head adenocarcinoma; prognosis 6 mos. or less; usually metastasis at presentation
Q636. Pancreatic Cancer - Risk factors
A636. smoking; chronic pancreatitis; high-fat diet; long-standing DM
Q637. Pancreatic Cancer - History/PE
A637. abdominal pain radiates to back; painless jaundice; loss of appetite; n/v; weight loss; Courvoisier's sign - palpable NT gallbladder; Trousseau's sign - migratory thrombophlebitis
Q638. Pancreatic Cancer - Dx
A638. CT; US; ERCP
Q639. Pancreatic Cancer - Tx
A639. Palliative; Whipple – pancreaticoduodenectomy, if no evidence of mets (10-20%); chemo - 5-FU, gemcitabine
Q640. Jaundice; What is it; Causes
A640. excess bilirubin in blood; pathological in adults from overload, damage to liver, inability to excrete causes; congenital (Gilbert's, Dubin-Johnson, Crigler-Najjar); hemolytic anemia; hepatitis; alcoholic cirrhosis; obstruction; pancreatic ca
Q641. Hepatitis - History/PE
A641. Acute Viral:; incubation period - virus multiplies & spreads, no Symptoms; prodromal period – anorexia, malaise, n/v, fever, RUQ pain, joint pain (occasionally), 3-10 days- urine darkens; icteric phase – jaundice, systemic Symptoms regress, patient feels better despite worsening jaundice, liver enlarged and tender, jaundice peaks 1-2 wks, then fades; acute usu resolves spontan in 4-8 weeks Chronic hepatitis: lasts > 6 mos. many patients asymp - esp. HCV; malaise, anorexia; jaundice - usu absent, scleral icterus; tender hepatomegaly, splenomegaly, lymphadenopathy, spider nevi, palmar erythema; autoimmune - can involve any body sys
Q642. Chronic Hepatitis - Etiologies
A642. HCV (80% with HCV progress); HBV (10%, cum or sin HDV prog); autoimmune hepatitis; alcoholic hepatitis; nonalcoholic steatohepatitis; right-sided heart failure; Wilson's; hemochromatosis; a1-antitrypsin deficiency; neoplasm; drug-induced disease – INH, methyldopa, acetaminophen, nitrofurantoin
Q643. Hepatitis - Dx
A643. WBC - normal count, relative leukocytosis; very high ALT and AST; high bilirubin; high alkaline phosphatase; hypoalbuminemia (chronic); hepatitis serology; severe cases - PT prolonged (all clotting factors except factor VIII made by liver); Biopsy; autoimmune – ANA, anti-LKM1 antibody, anti-smooth muscle antibody, antimitochondrial antibody
Q644. Hepatitis - Tx
A644. Etiology specific; monitor for resolution of Symptom; severe alcoholic - steroids; autoimmune -, steroids, azathioprine; chronic HBV - IFN-a, lamivudine (3TC), adefovir; chronic HCV – peginterferon, IFN-B, ribavirin; end-stage liver failure - liver transplant; fulminant hepatic failure – ICU, emergent transplant
Q645. Hepatitis - Complications
A645. Cirrhosis; liver failure; hepatocellular ca; mortality in 5 yrs (50%)
Q646. Hepatitis - IgM HAVAb
A646. IgM Ab to HAV - best test to detect active hepatitis A
Q647. Hepatitis - HBsAg
A647. Ag on surface of HBV; continued presence indicates carrier state
Q648. Hepatitis - HBsAb
A648. Ab to HBsAg; provides immunity to hep B
Q649. Hepatitis - HBcAg
A649. Ag associated with the core of HBV
Q650. Hepatitis - HBcAb
A650. Ab to HBcAg; positive during window period; indicator of recent disease
Q651. Hepatitis - HBeAg
A651. A second, different antigenic; determinant in the HBV core; important indicator of transmissibility (BEware)
Q652. Hepatitis - HBeAb
A652. Ab to e antigen; indicates low transmissibility
Q653. Infectious Diarrhea; Campylobacter; History
A653. Most common etiology of infectious diarrhea; Ingestion of contaminated food or water; Affects young kids and young adults; Usually last 7-10 days
Q654. Infectious Diarrhea; Campylobacter; PE
A654. Fecal RBCs and WBCs
Q655. Infectious Diarrhea; Campylobacter; Comments
A655. Rule out appendicitis and IBD
Q656. Infectious Diarrhea; Campylobacter; Tx
A656. Erythromycin
Q657. Infectious Diarrhea; C. difficile; History
A657. Recent tx with antibiotics; cephalosporins, clindamycin; Affects hospitalized adult pt; Watch for toxic megacolon
Q658. Infectious Diarrhea; C. difficile; PE
A658. Fever; abdominal pain; possible systemic toxicity; Fecal RBCs and WBCs
Q659. Infectious Diarrhea; C. difficile; Comments
A659. Most commonly in large bowel; can involve small bowel; ID C. Diff toxin in stool
Q660. Infectious Diarrhea; C. difficile; Tx
A660. PO metro or vanco; IV metro if can't tolerate; oral meds
Q661. Infectious Diarrhea; Entamoeba histolytica; History
A661. Contaminated food or water; history of travel in dev. countries; Incubation period can last up to 3 mos.
Q662. Infectious Diarrhea; Entamoeba histolytica; PE
A662. Severe abdominal pain; fever; Fecal RBCs and WBCs
Q663. Infectious Diarrhea; Entamoeba histolytica; Comments
A663. Chronic amebic colitis; mimics IBD
Q664. Infectious Diarrhea; Entamoeba histolytica; Tx
A664. Steroids can lead to; fatal perforation; Tx with metro
Q665. Infectious Diarrhea; E. Coli O157:H7; History
A665. Contaminated food - undercooked hamburger, apple cider; Affects kids and the elderly; Usually lasts 5-10 days
Q666. Infectious Diarrhea; E. Coli O157:H7; PE
A666. Severe abdominal pain; low-grade fever; vomiting; Fecal RBCs and WBCs
Q667. Infectious Diarrhea; E. Coli O157:H7; Comments
A667. Must rule out GI bleed and ischemic colitis; HUS possible complication
Q668. Infectious Diarrhea; E. Coli O157:H7; Tx
A668. Avoid Antibiotics therapy; resistance has increased
Q669. Infectious Diarrhea; Salmonella; History
A669. Contaminated poultry or eggs; Affects young kids and; the elderly; Usually lasts 2-5 days
Q670. Infectious Diarrhea; Salmonella; PE
A670. Prodromal headache; fever; myalgia; abdominal pain; Fecal WBCs
Q671. Infectious Diarrhea; Salmonella; Comments
A671. Sepsis; Sickle cell patients susceptible to osteomyelitis
Q672. Infectious Diarrhea; Salmonella; Tx
A672. Tx bacteremia or at-risk patients; (sickle cell) - oral quinolone or TMP-SMX
Q673. Infectious Diarrhea; Shigella; History
A673. Extremely contagious; transmitted between people; Affects young kids and institutionalized patients
Q674. Infectious Diarrhea; Shigella; PE
A674. Fecal RBCs and WBCs
Q675. Infectious Diarrhea; Shigella; Comments
A675. Can => severe dehydration; Can => febrile seizures in the very young
Q676. Infectious Diarrhea; Shigella; Tx
A676. TMP-SMX to decreased person-to-person spread
Q677. Achalasia; Features; Secondary Causes
A677. Increased tone; decreased or abnormal peristalsis; decreased inhib neurons in LES smooth muscle; secondary causes – Chagas, gastric carcinoma, lymphoma, scleroderma
Q678. Achalasia - Dx
A678. Barium swallow - always 1st; manometry; EGD - to rule out gastric carcinoma; or lymphoma
Q679. Achalasia - Tx
A679. Pneumatic dilation; botulinum toxin - every 2 yrs. Ca2+ chan blockers & nitrates; surgical myotomy - definitive
Q680. Scleroderma - Features
A680. Mid or distal esophagus; decreased or no peristalsis; LES incompetent => GERD Symptoms; progressive dysphagia
Q681. Scleroderma - Dx
A681. Barium swallow 1st; motility studies
Q682. Scleroderma - Tx
A682. Antireflux
Q683. Diffuse Esophageal Spasm - Features
A683. Nonperistaltic spontaneous contractions; usually due to degeneration of nerve processes; chest pain; dysphagia
Q684. Diffuse Esophageal Spasm - Dx
A684. Barium swallow - "corkscrew"; manometry confirms
Q685. Diffuse Esophageal Spasm - Tx
A685. Ca2+ chan blockers & nitrates
Q686. Nutcracker Esophagus - Features
A686. Increased excitatory activities => high-amplitude contractions; chest pain; dysphagia
Q687. Nutcracker Esophagus - Dx
A687. Manometry
Q688. Nutcracker Esophagus - Tx
A688. Ca2+ chan blockers & nitrates
Q689. Familial Polyposis Syndromes; What causes it; Three Names
A689. Caused by adenomatous polyps which transform into cancer; AD; Familial Polyposis Coli; Gardner Syndrome; Turcot Syndrome
Q690. Familial Polyposis Syndromes; Familial Polyposis Coli; What is it
A690. Thousands of colonic polyps; deletion in chromosome 5; 100% malignancy if total colectomy not done
Q691. Familial Polyposis Syndromes; Gardner Syndrome; What is it
A691. Polyps & osteomas
Q692. Familial Polyposis Syndromes; Turcot Syndrome; What is it
A692. Polyps & CNS tumors
Q693. Peutz-Jeghers Syndrome; What is it
A693. Not malignant; hamartomatous polyps in large & small intestines; mucocutaneous pigmentation
Q694. Juvenile Polyposis Syndrome; What is it
A694. Not malignant; hamartomatous polyps in large & small intestines
Q695. Hereditary NoNPOlyposis Syndrome (HNPCC); What is it
A695. Also called Lynch Syndrome; AD; mutations of several genes; colon ca from normal mucosa; cancer History in 3 first-degree relatives, 2 generations, 1 < 5 y/o; associated with ovarian & endometrial cancer
Q696. A1-Antitrypsin Deficiency - What is it
A696. AR => chronic hepatitis & cirrhosis; 20% of liver dis. in neonates
Q697. A1-Antitrypsin Deficiency - History
A697. Asymp transaminase increased in patient with emphysema
Q698. A1-Antitrypsin Deficiency - Dx
A698. Electrophoresis; confirm by low serum levels
Q699. A1-Antitrypsin Deficiency - Tx
A699. Liver transplant cures
Q700. NonUlcer Dyspepsia - What is it
A700. Abdominal pain or fullness & bloating; may be postprandial; gastric acid secretion is normal; may have abnormal gastric or small intestine motility
Q701. NonUlcer Dyspepsia - Dx
A701. Normal EGD or barium
Q702. Dumping Syndrome - What is it
A702. Rapid emptying from stomach; => shift of fluids and; distention of small intestines; associated with PUD surgery
Q703. Dumping Syndrome - History/PE
A703. Diaphoresis; lightheaded; palpitations; n/v; 30 min. postprandial; if 90 min. postprandial - CHO- or sucrose-rich meals
Q704. Dumping Syndrome - Dx
A704. Clinical History
Q705. Dumping Syndrome - Tx
A705. Restrict sweets; frequent small meals; decreased liquid intake with meals
Q706. What test(s) diagnose small bowel obstruction?
A706. The most accurate test for small bowel obstruction is a combination of the abdominal X-ray and the abdominal CT scan. There is no blood test to diagnose obstruction and there are no findings on endoscopy.
Q707. What does small bowel obstruction look like on abdominal x-ray?
A707. There are multiple air-fluid levels seen throughout the bowel.
Q708. When do you use abdominal X-ray?
A708. Suspected small bowel obstruction is the only use for the abdominal X-ray. Look for a patient with abdominal pain and distension; hypoactive or absent bowel sounds, possible electrolyte abnormalities such as potassium; calcium, or magnesium disorders; and failure to pass either stool or flatus. This is normal after abdominal surgery.
Q709. What does a barium enima do?
A709. BE creates a "contrast" picture to outline the lining of the retum and colon. BE can be used in detecting colorectal cancers, polyps, diverticulosis, and bowel obstruction and to evaluate the extent of inflammatory bowel disease.
Q710. When is BE contraindicated?
A710. Patient's who may have peritonitis or bowel perforation must not undergo this test because the contrast material can leak into the peritoneum through the perforation. BE is also contraindicated in diverticulitis, in which it increases the risk of perforation.
Q711. Compare BE and Colonoscopy if you are suspecting a lesion in the colon.
A711. Colonoscopy is superior to enema in that it can directly biopsy lesions or remove polyps. BE is NEVER the right answer to the question, "What is the most accurate test?" if colonoscopy is one of the choices.
Q712. What is Capsule Endoscopy?
A712. It is a capsule the size of a large pill, with a camera and a small transmitter. Once swallowed, it begins transmitting images of the inside gastrointestinal tract to a receiver worn by the patient. The doctor can review 6 hours worth of pictures for any abnormalities.
Q713. When do you use Capsule Endoscoopy?
A713. Capsule endoscopy is the procedure of choice for suspected small bowel bleeding that was not detected with upper or lower endoscopy.
Q714. What are Amylase/Lipase levels?
A714. Amylase and lipase are the initial test in the diagnosis of acute pancreatitis. Lipase is more specific for the pancreas. Amylase can be elevated from damage to the salivary glands, esophagus, or small bowel.
Q715. When do you answer amylase and lipase levels?
A715. Answer amylase/lipase for a patient presenting with the acute onset of severe epigastric pain radiating to the back. Such a patient may have a history of alcohol abuse or gallstones.
Q716. What is the most accurate test for acute pancreatitis?
A716. Abdominal CT scan. It is more accurate than Ranson's criteria. Pancreatic necrosis on a CT scan is etremely specific for severe pancreatitis and is the main indicator of the need for a pancreatic biopsy.
Q717. What is Antiendomysial/ Antigliadin Antibodies?
A717. Serum assay for endomysial and antigliadin antibodies are made against wheat or gluten antigens and the villous (endomysial) lining fo the small intestine. They are used to confirm the diagnosis of celiac disease.
Q718. When are Antiendomysial/ Antigliadin Antibodies the answer?
A718. Look for a case of robable celiac disease with oily, greasy diarrhea, foul-smelling stool without evidence of chronic pancreatitis. they are the tests to answer to confirm gluten-sensitive enteropathy after Sudan black stain has confirmed a fat malabsorption.
Q719. What is the most accurate test for celiac disease?
A719. Small bowel biopsy. It must be done to exclude lymphoma as well as to diagnose the disease.
Q720. What is the Antimitochondrial Antibodies (AMA) test for?
A720. Serum screening for antimitochondrial antibodies is the best initial test to make a specific diagnosis of primary biliary cirrhosis (PBC).
Q721. When do you answer AMA?
A721. Look for a middle-aged female presenting with itching (pruritus) and an elevated alkaline phosphatase with a normal bilirubin.
Q722. What is the most accurate test for PRIMARY BILIARY CIRRHOSIS?
A722. Liver biopsy.
Q723. What is anti-Smooth Muscle Antibodies?
A723. Serum assay detection of anti-smooth muscle antibodies (ASMA) is the best initial test for atuoimmunie hepatitis.
Q724. When do you answer ASMA?
A724. Answer ASMA when you are shown a young female with a liver disease who does not drink or have inflammatory bowel disease or infectious hepatitis.
Q725. What other immune markers are associates with autoimmune hepatitis?
A725. Autoimmune hepatitis is associated with antinuclear antibodies (ANA) and antibodies to liver/kidney microsome type 1 (anti-LKM1).
Q726. What is the most accurate test for autoimmune hepatitis?
A726. Liver biopsy is the most accurate test for autoimmune hepatitis and most other liver diseases.
Q727. For which clinical condition is Barium Esophagram the best initial test?
A727. Barium esophagram is, generally, the best initial test for dysphagia. This is not in scenarios where there are clear signs of obstruction, for which upper endoscoopy would be the best initial test. For achalasia, barium esophagram shows a "bird's beak" at the gastroesophageal junction. In diffuse esophageal spasm barium esophagram shows a "corkscrew" pattern at the time of spasm.
Q728. For which conditions is Barium Esophagram the most accurate test?
A728. Barium esophagram is the most accurate test for esophageal rings, webs, and idverticuli.
Q729. What is the most acurate test for abnormalities detected with a barium esophagram?
A729. In achalasia, esophageal spasm, and nutcracker esophagus, the most accurate test is manometry. With cancer, the most accurate test is endoscopy for a biopsy.
Q730. What is a Bernstein Test?
A730. The Bernstein test is to diagnose gastroesophageal reflux disease.
Q731. How is a Bernstein Test done?
A731. The Bernstein test involves the placement of a nasogastric tube into the esophagus with the tip at the end of the esophagus near the gastroesophageal junction. Dilute hydrochloric acid is instilled or dripped into the esophagus in an attempt to reproduce the symptoms of reflux disease. This is a older test that has been made obsolete by the use of empiric trials of PPIs or the 24-hour pH monitor.
Q732. When is a Bernstein Test the right answer?
A732. The Bernstein test is always WRONG to do. When you see it in the answers as a diagnostic test, do not choose it.
Q733. What is a Bleeding Scan?
A733. The bleeding scan, or technetium-labled RBC scanning, is performed in a patient with small amounts of active lower GI bleeding in which the bleeding site could not be identified with endoscopy. B; leeding scan is sensitive, but not specific. If the bleeding scan is positive, you cannot identify the precise etiology of the bleeding. Angiography is another diagnostic option for the patint with persistent, severe GI bleeding wihtout an identified source.
Q734. When do you answer bleeding scan?
A734. Look for a patient who presents with severe gastrointestinal bleeding in whom the lower endoscopy is unable to find a source. The bleeding continues and the patient may still require transfusions.
Q735. What is Ceruloplasmin?
A735. Serum ceruloplasmin levels and the presence of Kayser- Fleischer rings on exam are the best initial tests for Wilson's disease.
Q736. When do you answer ceruloplasmin?
A736. Look for a patient wiht the convination of unexplained hepatic and psychiatric abnormalities with a movement disorder.
Q737. Is a high or low value abnormal?
A737. An exremely low serum ceruloplasmin level should be taken as strong evidence for the diagnosis of Wilson's disease.
Q738. What additional tests would confirm the diagnosis?
A738. Twenty-four-hour urine copper excretion will be abnormally high. The most accurate test is the liver biopsy. Wilson's disease is a disease of copper overload. this is because of the inability of the liver to incorporate copper into the protein ceruloplasmin for excretion into the bile. This leads to hepatic copper accumulation and injury. This eventually spills into the bloodstream and deposits into the brain (behavior and movement changes), kidneys (renal insufficiency), and cornea (Kayser-Fleischer rings).
Q739. When do we use colonoscopy as a screen?
A739. General Population: Every 10 years for patients over age 50. Colonoscopy is superior to occult blood test or simoidoscopy. Single family member with colon cancer: Start at age 40 or 10 years earlier than thefamily member's diagnosis, whichever is earlier. Hereditary non-polyposis cancer syndrome (HNPCC or Lynch syndrome): Tree family members, two generations, one prmature. Premature means the cancer was before age 50. Start at age 25 and repeat every 1-2 years.
Q740. What is D-Xylose Test?
A740. D-xylose testing is used in determining the etiology of different malabsorption syndromes. D-xylose is used to differentiate between intestinal malabsorption and chronic pancreatitis. Celiac disease is the most common cause of intestinal malabsorption. D-xylose is a sugar that should be absorbed if the small bowel mucosa is intact. It does not require digestive pancreatic enzymes. A low D-xylose level in the urine indicates that the intestinal mucosa is defective and that D-xylose was not absorbed.
Q741. When do you answer D-xylose testing?
A741. Look for a patient with foul-smelling stool without blood, who has weight loss, malnutrition, fat in stool, and a positive Sudan black stain.
Q742. What is the most accurate test for malabsorption syndromes?
A742. The most accurate test of the small bowel mucosa is a biopsy to assess histology and architecture.
Q743. What disease will make D-xylose abnormal?
A743. D-xylose test is abnormal with celiac disease, tropical sprue, and Whipple's disease.
Q744. What is an endoscopic Retrograde Cholangiopancreatography (ERCP)?
A744. ERCP is a direct visualization of hte biliary tract.
Q745. For which condition is an ERCP most accurate?
A745. ERCP is the most accurate diagnostic test for stones in teh biliary system. ERCP is also the most accurate test for primary sclerosing cholangitis (PSC).
Q746. What are the characteristics lesion of sclerosing cholangitis?
A746. In sclerosing cholangitis there are multiple intrahepatic and / or extrahepatic strictures of the biliary tract on cholangiography; This gives the biliarry radicles a "beaded" appearance.
Q747. When do I answer ERCP?
A747. The strongest indication for ERCP is when the patient has high fever, chills, right upper-quadrant abdominal pain, and jaundice. ERCP is both diagnostic and therapeutic because you can remove the stone. For PSC, look for a patient with a history of ulcerative colitis complaining of pruritus and jaundice with a negative hepatitis profile and negative abdominal sonogram.
Q748. What is Esophageal manometry used for?
A748. Esophageal monometry isused to establish the diagnosis of dysphagia or unexplained chest pain when there is no mechanical obstruction.
Q749. How is Esophageal manometry done?
A749. Esophageal manometry consists of a transducer placed in teh esophagus to record pressure
Q750. When do you answer esoophageal manometry?
A750. Look for a case of dysphagia with an inconclusive barium radiograph or upper endoscopy. If the stem of the question clearly describes a motility problem, you do not have to do either endoscopy or barium prior to doing the manometry;; for example, achalasia, diffuse esophageal spasm, or nutcracker esophagus.
Q751. What is fecal occult blood testing?
A751. Fecal occult blood testing (FOBT) is the screening of normal brown stool for microscopic amounts of blood not grossly visible. Gross blood or dark stool, such as melena, does not occur until >100ml of blood has been lost in the bowel. The FOBT will detect as lettle as 5-10ml of blood.
Q752. When is fecal occult blood testing the right answer?
A752. FOBT is a screening test for occult blood in the stool. FOBT is an option for screening for colon cancer in those above the age of 50. In colon cancer screening the three methods of screening, are: colonoscopy every 10 years, sigmoidoscopy every 3-5 years, FOBT every year after age 50.
Q753. What do you do for a positive fecal occult blood test?
A753. A positive FOBT should be investigated with a colonoscopy.
Q754. What is Fecal Leukocytes a test for?
A754. Fecal leukocytes are used to assess the etiology of acute diarrhea.
Q755. What diseases is Fecal Leukocytes associated with?
A755. Invasive and inflammatory causes of iarrhea can give both blood as well as fecal leukocytes. Diseases such as Salmonella, Shigella, Campylobacter, etc., can give both blood as well as white cells in the stool.
Q756. When do you answer fecal leukocytes?
A756. Look for a patient with diarrhea with no blood in whom you are trying to see if there is an invasive form of diarrhea. Fecal leukocytes are not found with diarrhea secondary to viruses, most protozoans, or pre-formed toxins such as Bacillus cereus or staph.
Q757. What is the Gastrin level?
A757. Serum gastrin levels should be measured when you suspect Zollinger-Ellison syndrome (ZES).
Q758. When do you answer gastrin level as the best initial test?
A758. Look for ulcers that are large (>1cm), rcurrent, distal, and multiple. A gastrin level greater than 1,000 pg/ml is diagnostic. REMEMBER: Everyone on a PPI has a high gastrin level.
Q759. What additional test would you like if this is not diagnostic?
A759. The secretin stimulation test can confirm ZES when serum gastrin concentration testing is nondiagnostic. In ZES, gastrin levels do not go down with secretin.
Q760. What disease is the syndrome part of?
A760. ZES is associated with MEN I: Hyperharathyroidism; Pituitary adenomas; Pancreatic islet cell/gastrointestinal adenomas
Q761. What is gastrograffin?
A761. Gastrograffin is a water-soluble form of radio-opaque constrast material that is used when there is the possibility that there has been organ perforation and the material may leak through into the peritoneum. Gasrograffin is used as the diagnostic test of choice for Boerhaave's syndrome, or esophageal perforation, because barium going through a perforation causes inflammation.
Q762. When do you answer gastrograffin?
A762. Look for a patient presenting with a recent history of severe retching followerd by severe chest pain, dyspnea, shock, and possible crepitation. Initial chest X-ray would show free air in teh mediastinum or peritoneum.
Q763. What is the most accurate test for Boerhaave's syndrome?
A763. The most accurate test is a CT scan.
Q764. What is HFE gene, and C282Y mutation?
A764. The HFE gene and C282Y mutation both lead to the overabsorption of iron in teh duodenum. They are confirmatory tests for hemochromatosis. These genetic tests and an MRI can eliminate the need for liver biopsy to diagnose hemochromatosis.
Q765. When do you answer HFE gene, or C282Y mutation?
A765. Answer HFE gene and C282Y mutation when you are shown a patient with the characteristics of hemochromatosis and abnormal iron studies consistent with hemochromatosis. The patient will have liver disease, skin hyperpigmentation, joint pain, diabetes, and infertility. The iron and ferritin levels will be elevated and the iron- binding capacity will be markedly dimished.
Q766. What is HIDA Scanning?
A766. HIDA scan is used when you suspect acute cholecystitis with a nondiagnostic ultrasonography.
Q767. When do you answer HIDA scan?
A767. Answer HIDA scan when you see either: Gallstones without gallbladder edema and ultrasound Murphy's sign, or; Gallbladder edema and ultrasound Murphy's sign without gallstones.
Q768. How does HIDA scan work?
A768. HIDA is taken up by hepatocytes and excreted into bile and concentrated in teh gallbladder. If the gallbladder does not opacify, it means that there is an obstruction of the cystic duct. Leakage into the pericholecystic space suggests perforation. On a normal scan the gallbladder should opacify.
Q769. When is the HIDA scan the most common wrong answer?
A769. The HIDA is not recommended in critically ill patients who should be taken to the operating room. If the diagnosis is obvious, the HIDA scan is not necessary, surgery is necessary.
Q770. What is PAS staining used for?
A770. PAS staining on a small bowel biopsy specimen is the most accurate test for Whipple's disease.
Q771. When do you answer PAS staining?
A771. Look for chronic multisystem illness, initially rheumatological (80%), then with fat malabsorption (75%), fever (50%), and ocular and neurological complaints..
Q772. How do you treat Whipple disease?
A772. Initial course of Ceftriaxone followed by trimethoprim- sulfamethoxazole for 1 year.
Q773. What is 24-Hour pH monitoring used for?
A773. Twenty-four -hour esophageal pH recording is indicated to document abnormal esophageal acid exposure.
Q774. When do you answer 24-Hour pH monitoring?
A774. It is the appropriate test in the following scenarios:; 1) Persistent symptoms of gastroesophageal reflux disease (GERD) after at least 4 weeks of treatment with a PPI. 2) To exclude GERD in a patient with unexplained chest pain; 3) GERD sysptoms wit a negative upper endoscopy wen you are considering antireflux surgical repair. 4) To assess the efficacy of antireflux surgery; 5) To evaluate patients with laryngitis, pharyngitis, chronic cough, nonallergic asthma (reflux-induced asthma)
Q775. For what diseases do you answer secretin stimulation testing?
A775. Secretin stiulation is a rarely used test for two completely separate diseases: Zollinger-Ellison syndrome (ZES) and chronic pancreatitis.
Q776. What is secretin stimulation testing?
A776. ZES: You inject secretin intravenously and measure the level of gastrin in blood. Secretin should inhibit gastrin and lower the levels of gastrin in a normal person. In ZES, there is a failure to suppress gastrin levels. Chronic pancreatitis: Normally, secretin should induce a large release of bicarbonate from the pancreas into the duodenum and measure the release of bicarbonate from the sphincter of Oddi. With chronic pancreatitis, the pancreas is too burned out and tired to do anything.
Q777. When do you answer secretin stimulation test?
A777. Answer secretin stimulation testing in ZES when the patient has large, recurrent, and multiple ulcers, but has a nondiagnostic fasting serum gastrin concentration. For chronic pancreatitis, look for a patient with fat malabsorbtion with no evidence of celiac disease and a normal D-xylose test.
Q778. Who should upper endoscopy screening be offered to?
A778. Screening upper endoscopy should be performed in patients with gastroesophageal reflux disease (GERD) in whom the symptoms have been present for more than 5 years. You are screening to see if there is Barrett's esophagus, which is when the lower esophagus is transforming form squamous to columnar epithelium. Screening for the presence of esophageal varices should be done in those with cirrhosis.
Q779. What is the treatment for an abnormal upper endoscopy?
A779. Barrett's esophagus is treated with proton pump inhibitors with a repeat upper endoscopy every 2-3 years. Low-grade esophageal dysplasia is treated with PPIs with a repeat upper endoscopy in 6 months. Those with varices should receive propranolol to decrease the risk of bleeding.
Q780. What is a 72-Hour Fecal Fat test used for?
A780. The 72-hour fecal fat collection is an old test for intestinal malabsorption. As the name implies, you are supposed to collect 3 days' worth of stool in order to have a very sensitive test for fat malabsorption. A single test of a Sudan black stain of the stool for the presence of fat is usually sufficient.
Q781. When do you answer 72 -hour fecal fat test?
A781. The 72-hour fecal fat collection is the single most accurate test for fat malabsorption; however, it is virtually never done and is most often a WRONG answer on your test. The 72-hour fecal fat is the answer if you strongly suspect fat malabsorption and the Sudan black stain is negative.
Q782. What is a string test?
A782. The string test is an old test for giardiasis. The string test samples the duodenal mucosa without the need of endoscopy. A string is swallowed and left in place with one end in the duodenum and the other end hanging out through the patient's mouth.
Q783. When is a string test the answer?
A783. String test is always the WRONG answer. Stool ova and parasite testing is sufficiently sensitive and less invasive. Stool Giardia antigen testing by ELISA is the single most accurate test for Giardia and is considerably less invasive.
Q784. What is a Sudan Black Stain?
A784. Stool staining with Sudan black is used to detect steatorrhea as a sign of fat malabsorption.
Q785. What is the most accurate test for fat malabsorption.
A785. Seventy-two-hour quantitative estimation of stool fat is the most accurate test because of increased sensitivity. The 72-hour estimation is almost always the wrong answer.
Q786. When do I answer Sudan black stain?
A786. Answer Sudan black stain when you see a patient with chronic pale, greasy, malodorous diarrhea, and no evidence of infection.
Q787. What is Fasting Transferrin saturation?
A787. Serum measurement of fasting transferrin saturation is the best initial test to diagnose hereditary hemochromatosis (HH) as well as the screening test for asymptomatic family members. Fasting transferrin saturation = (serum iron/TIBC)
Q788. When do you answer fasting transferrin saturation?
A788. Answer fasting transferrin satruation when you see a ase of liver disease with oint pain, diabetes, cardiomyopathy, skin hyperpigmentation, and infertility.
Q789. How would you confirm an abnormal test of fasting transferrin saturation?
A789. Liver biopsy is the most accurate test.
Q790. What is the pathogenesis of hereditary hemochromatosis (HH)?
A790. The pathogenesis is genetically determined abnormal increase in intestinal absorption of iron.
Q791. When is the optimal timing of screening for HH?
A791. The optimal timing for screening family members is between the ages of 18 and 30, before organ damage (e.g., cirrhosis) has occurred.
Q792. What is serum trypsinogen concentration used for?
A792. Serum assay of trypsinogen is used when you suspect chronic pancreatitis in a patient with steatorrhea. This is the only test that is specific for steatorrhea of pancreatic origin. Trypsinogen levels are low if the fat malabsorption is form a burned-out pancreas.
Q793. When is serum trypsinogen concentration the answer?
A793. Answer trypsinogen level only after Sudan black stin has confirmed a fat malabsorption. Antigliadin and anti-endomysial antibodies should be normal. Low trypsinogen levels are specific but not sensitive for chronic pancretitis.
Q794. What is the urea breath test?
A794. Urea breath testing is the measurement of radiolabled carbon dioxide after the oral ingestion of labeled urea. H. pylori splits urea wuth urease. The labeled carbon is in the urea and is released as labeled carbon dioxide.
Q795. When is the urea breath test used?
A795. Urea breth testing is best used to confirm the eradication of H. pylori immediately after treatment. Serology does not rapidly improve after treatment. If an ulcer is found at endoscopy, the test of choice will be biopsy, not the urea breth test.
Q796. When do you answer urea breath test?
A796. Answer urea breath test with a patient with epigastric pain that does not improve or that recurs after a proton pump inhibitor and antibiotics have been given. There is no routine test of cure for H. pylori. You do not do the test if the patient feels better after treatment.