River's Gi

Front 1

Esophagus spans which vertebral levels?

Back 1

C6-T11

Front 2

Layers of the esophagus?

Back 2

mucosa -> submucosa -> muscle; no adventicia

Front 3

Upper esophageal sphincter? level and composition...

Back 3

cricopharyngeus muscle; C6

Front 4

Muscle composition from prox -> distal of esophagus?

Back 4

upper 1/3 -> striated
middle 1/3 -> both
lower 1/3 -> smooth

Front 5

Oropharyngeal (transfer) dysphagia?

Back 5

problems initiating swallowing; caused by neuromuscular (80%) dz or proximal inflammatory/infectious dz

Front 6

Difficulty swallowing liquids (especially cold)?

Back 6

Transfer dysphagia; typically neuromuscular

Front 7

Schatzki's ring?

Back 7

a lower esophageal web near the GE junction

Front 8

Most common cause of lower esophageal dysphagia?

Back 8

obstruction from cancer

Front 9

Causes of upper esophageal dysphagia? (early in swallowing, high in neck)

Back 9

webs, CA, thyromegaly, aortic aneurysm, LA enlargement, Zenker's

Front 10

Causes of lower esophageal dysphagia? (late in swallowing, stuch in chest)

Back 10

CA, achalasia, reflux induced spasm and stricture, Schatzki's ring

Front 11

Reflux v. ACS?

Back 11

R-> positional (including leaning forward), water/acid brash, moves -> abdomen, not arms, change with food, antacids, cold liquids

Front 12

causes of esophagitis?

Back 12

fungal, HSV, VZV, CMV, mycobacterium, radiation, alkali, tetracyclines, KCl, FeSO4

Front 13

Laterality of Mallory-Weiss v. Boerhaave's?

Back 13

MW on right, B on left

Front 14

Water-soluble contrast?

Back 14

gastrografin

Front 15

Most common sites of esophageal impaction?

Back 15

cricopharyngeus (C6) (kids), aortic arch (T4), and LES (T10) (adults)

Front 16

Aluminum tabs: radiodense or radiolucent?

Back 16

radiolucent

Front 17

Rx for distal esophageal food impaction?

Back 17

NTG 0.4 mg SL
Glucagon 1mg IV, then 2mg IV 20 min later
Nifedipine 10 mg SL

Front 18

Papain in esophageal fb?

Back 18

no -> 3% incidence of perforation

Front 19

Dimensions of GI fbs that can pass?

Back 19

5cm x 2 cm

Front 20

layers of the stomach?

Back 20

mucosa (epith, lamina prop, musc mucosa) -> submucosa -> muscularis -> serosa

Front 21

Most common sites of ulcers?

Back 21

lesser curvature and first part of the duodenum

Front 22

Stress ulcer?

Back 22

caused from stress -> does not invade the muscularis mucosae; called hemorrhagic gastritis; body and fundus

Front 23

Peptic ulcer v duodenal?

Back 23

P- pain with food
D- pain 2-3 hours post food, improved with food

Front 24

Peptic ulcer physiology v. duodenal?

Back 24

P- mucosal errosion
D- increased acid volume to duodenum

Front 25

Portal steal?

Back 25

increased portal circulation -> decreased coronary flow -> pain

Front 26

Reflux v. ACS?

Back 26

R-> positional (including leaning forward), water/acid brash, moves -> abdomen, not arms, change with food, antacids, cold liquids

Front 27

causes of esophagitis?

Back 27

fungal, HSV, VZV, CMV, mycobacterium, radiation, alkali, tetracyclines, KCl, FeSO4

Front 28

Laterality of Mallory-Weiss v. Boerhaave's?

Back 28

MW on right, B on left

Front 29

Water-soluble contrast?

Back 29

gastrografin

Front 30

Most common sites of esophageal impaction?

Back 30

cricopharyngeus (C6) (kids), aortic arch (T4), and LES (T10) (adults)

Front 31

Aluminum tabs: radiodense or radiolucent?

Back 31

radiolucent

Front 32

Rx for distal esophageal food impaction?

Back 32

NTG 0.4 mg SL
Glucagon 1mg IV, then 2mg IV 20 min later
Nifedipine 10 mg SL

Front 33

Papain in esophageal fb?

Back 33

no -> 3% incidence of perforation

Front 34

Dimensions of GI fbs that can pass?

Back 34

5cm x 2 cm

Front 35

layers of the stomach?

Back 35

mucosa (epith, lamina prop, musc mucosa) -> submucosa -> muscularis -> serosa

Front 36

Cimetidine?

Back 36

Inhibits c-p450 system -> increases drug levels. CNS dysfunction, gynecomastia, thrombocytopenia

Front 37

Why should PPIs be short-term?

Back 37

increased pneumonia, C. diff infection, osteoporosis, B12 defficiency, and interference with plavix

Front 38

Tx for PUD?

Back 38

H2 blocker, PPI, misoprotol, and sucralfate

Front 39

H. pylori? Tx?

Back 39

90% of duodenal and 70% of gastric
bismuth, flagyl, tetracycline
ranitidine/bismuth, biaxin, tetracycline
omeprazole, biaxin, amox

Front 40

Complications of PUD?

Back 40

bleeding, perforation, gastric outlet obstruction

Front 41

Rx in upper GI bleed for PUD?

Back 41

H2 blockers and pantoprazole have been shown to reduce rebleed, surgery and death

Front 42

PUD perforation leads to what?

Back 42

chemical peritonitis -> bacterial peritonitis; retroperotoneal perfs only give back pain

Front 43

Gastric outlet obstruction

Back 43

from healed ulcer or mass; early satiety, pain, vomiting, succusion splash, large stomach on x-ray

Front 44

Do perforated ulcers bleed?

Back 44

usually not

Front 45

Gallstone ileus on xray?

Back 45

pneumobilia and obstruction pattern; stone not always seen
pneumobilia is from fistula from gb to gut

Front 46

DDx when considering appendicitis?

Back 46

Yersinia gastroenteritis, mesenteric adenitis, PID, ectopic, ovarian cyst/torsion, pyelo, Crohn's and diverticular dz

Front 47

Causes of small bowel obstruction?

Back 47

adhesion (1), hernia (2), neoplasm, intuss, gallstones, bezoar, IBD, radiation

Front 48

Causes of large bowel obstruction??

Back 48

tumor (1) (left = obstruction, right = bleeding), tics, volvulus, fecal impaction

Front 49

Haustra v. valvulae conniventes?

Back 49

haustra = colon, not contiguous
vc = small bowel, contiguous

Front 50

Risk for sigmoid volvulus?

Back 50

chronic severe constipation
-> redundant sigmoid

Front 51

Cecal volvulus?

Back 51

pt's in 20's or 30's; incomplete embryologic fixation of cecum to posterior abdominal wall

Front 52

Causes of mesenteric ischemia?

Back 52

arterial occlusion (70%, emboli most common), decreased perfusion (20%, sepsis, shock), venous thrombosis (10%)

Front 53

Incarcerated v. strangulated hernias?

Back 53

incarcerated -> cannot reduce
strangulated -> ischemia occurs

Front 54

Direct hernia?

Back 54

Protrudes directly through hesselbach's triangle; rarely incarcerates; medial to inferior epigastric; age related

Front 55

Hesselbach's triangle?

Back 55

rectus medially, inferior epigastric laterally, inguinal ligament inferiorly

Front 56

Indirect hernia?

Back 56

through inguinal canal, lateral to inferior epigastrics; most common hernia, M = F; frequently incarcerates; congenital defect in processes vaginalis

Front 57

Femoral hernia?

Back 57

inferior to inguinal ligament; more common in women; frequently incarcerates

Front 58

Obturator hernia?

Back 58

obturator nerve through obturator foramen; elderly women -> pain and numbness medial thigh to knee

Front 59

Extraintestinal manifestations of Crohn's?

Back 59

arthritis, ankylosing spondy, vasculitis, thrombosis, gallstones, hepatitis, erythema nodosum, pyoderma gang, uveitis, iritis, kidney stones

Front 60

Complications from Crohn's?

Back 60

perianal dz, intestinal stricture, obstruction, fistula, abscess, toxic megacolon, 3x risk of cancer

Front 61

Tx for Crohn's flare?

Back 61

steroids, sulfasalazine, flagyl, azothioprine, 6mp

Front 62

Ulcerative colitis pathology?

Back 62

ulceration of rectum +/- continuous proximal spread; mucosa/submucosa only; ccrytp abscesses

Front 63

Perforation in UC?

Back 63

most common in first few episodes of UC.

Front 64

Complications of UC?

Back 64

hemorrhage, stricture, obstruction, toxic megacolon, 10-30 x risk of CA; scclerosing cholangitis -> cholangiocarcinoma

Front 65

Tx of C. diff?

Back 65

flagyl first-line, then oral vanc if necessary

Front 66

Anti-diarrheals in C. diff?

Back 66

makes worse and can lead to toxic megacolon

Front 67

Sx of diverticulitis?

Back 67

bleeding, crampy abd pain without focality, diarrhea

Front 68

Tx of symptomatic diverticulosis?

Back 68

high fiber diet, laxatives, anti-spasmodics

Front 69

Tx of diverticulitis?

Back 69

npo/clears, abx, fluids, easy on the narcotics -> constipation -> increased intraluminal pressure -> worse

Front 70

Thrombosed external hemorrhoid?

Back 70

> 48 hours -> analgesices, fiber, softeners, sitz bath
< 48 hours -> excision of clot -> sitz baths

Front 71

Anal fissure? Sentinel pile?

Back 71

posterior midline usually; anterior midline sometimes, o/w may be other dz. SP = skin tag on tear from chronicity

Front 72

Tx for rectal prolapse?

Back 72

reduction and stool softener

Front 73

Anorectal CA; prognosis by location?

Back 73

above dentate line (80%) is bad; below (20%) is much better

Front 74

Invasive v. toxogenic bacterial diarrheas?

Back 74

Invasive usually affects colon -> fecal wbc; tox affects small bowel -> no wbc
bacteria = 20% of diarrhea

Front 75

Invasive bacteria in diarrhea?

Back 75

campylobacter, salmonella, shigella, non-cholera vibrio, yersinia, enteroinvasive e. coli, enterohemorrhagic e. coli, c. diff

Front 76

Enterotoxic bacteria in diarrhea?

Back 76

S. aureus, B. cereus, ciguatera, scombroid, enterotoxogenic e. coli, c. perfringens, aeromonas hydrophilia, v. cholera

Front 77

Traveler's diarrhea?

Back 77

70% bacterial, 50+% enterotoxogenic E. coli; fluids, cipro or bactrum, no anti-diarrheals; bismuth works well

Front 78

Enterotoxogenic E. coli?

Back 78

traveler's diarrhea; self limited. pepto, abx, fluids, no anti-diarrheals; watery diarrhea wbc (-)

Front 79

Enterohemorrhagic E. coli?

Back 79

bloody, painful diarrhea. Abx increases HUS/TTP but does not shorten course. Produces shigatoxin.

Front 80

Shigella?

Back 80

bloody, painful diarrhea, high fever, leukocytosis with bandemia. Tx with cipro and fluids, no anti-diarrheals

Front 81

Complications of shigella?

Back 81

dehydration, Reiter's syndrome, arthralgias, HUS, febrile seizures, pneumonitis

Front 82

Risk factors for salmonella?

Back 82

bad food, immunocompromise, splenectomy, SSD, drug use, gastrectomy, H-2 blocker use

Front 83

Campylobacter enteritis? Tx? Complications?

Back 83

n/v/d, fever, focal abd pain, bloody stools, wbc (+), cipro, no anti-diarrheals; complications: Reiter's, HUS, Guillain-Barre

Front 84

Yersinia enterocolitis?

Back 84

fever, diarrhea -> bloody, sever abdominal pain. terminal ileitis or mesenteric adenitis (? appy on exam); can lead to erythema nodosum, polyarthritis); cipro/bacctrim, no anti-diarrheals; pepto

Front 85

C. perfringens diarrhea?

Back 85

ingest live organism -> toxin in the gut. Diarrhea WBC (-). Supportive tx and pepto

Front 86

C. diff colitis?

Back 86

abx -> crampy abd pain and diarrhea (+) wbc. Stop abx, fluids, flagyl or vanc PO. cx does not help (c. diff is normal flora); anti-diarrheals are contraindicated and predispose to infection

Front 87

Staff aureus gastroenteritis?

Back 87

most common cause of food poisoning. ingest preformed toxin -> 1-6 hours -> vomiting and diarrhea; supportive, pepto bismol

Front 88

Bacillus cereus food poisoning?

Back 88

early onset vomiting (1-6 hours) and/or later onset diarrhea, both with cramps. Tx symptomatically.

Front 89

Aeromonas hydrophila?

Back 89

bad well/stream water in children or AIDs... watery diarrhea, cramps, vomiting. Tx with bactrim or cipro; confirm with cx

Front 90

Vibrio cholera?

Back 90

2-6 days post ingestion -> copious watery diarrhea. hyperchloremic acidosis, hypokalemia, dehydration. Tx with fluids and doxycycline/cipro

Front 91

Vibrio parahemolyticus?

Back 91

most common bacterial enteritis in Japan; 12 hours post ingestion -> copious vomiting, cramping, diarrhea, (+) fever and fecal leukocytes; self limited, supportive tx

Front 92

Scombroid?

Back 92

mahi, mackerel, tuna -> heat stabile toxin ingestion that mimicks histamine; fish tastes metalic. Looks like allergic rxn; tx with benadryl/pepcid; epi if severe

Front 93

Ciguatera poisoning?

Back 93

15 min - 24 hours -> vomiting, diarrhea, myalgias, paresthesias, reversal of hot/cold, feel that teeth are loose; made worse by ETOH. tx- supportive, avoid ETOH for 3-6 months

Front 94

CCiguetera toxin is what?

Back 94

toxin produced by dinoflagellate ingested by fish, present in tissue. heat stabile; higher risk in older/bigger fish.

Front 95

Entamoeba histolytica sx?

Back 95

cysts passed fecal-orally; most are asymptomatic. AIDs, homosexuals, travelers. can lead to cramps, dysentery, flatulance, fever. Can cause extra-intestinal abscess (liver most common)

Front 96

E. histolytica, dx and tx?

Back 96

stool for cysts, or serology. Stool often neg in pts with extra-intestinal abscesses. Tx with iodoquinol or paromomcin + flagyl or tetracycline

Front 97

Giardia lamblia?

Back 97

most common parasite in US. streams or wells. inc. is 1-3 weeks, most never have sx. sx are bloating, diarrhea - frothy/foul. Dx by string test or stool for O+P. Tx with flagyl.

Front 98

Recurrent or refractory giardiasis?

Back 98

IgA deficiency

Front 99

Cryptosporidium?

Back 99

chronic diarrhea in AIDS, daycare. fecal-oral tx. sx are watery diarrhea, anorexia, cramps, flatulance. self-limited unless AIDS. ELIZA of stool. Tx with nitazoxanide in immunocompetent or Tx AIDS with HART if AIDS

Front 100

Isospora belli?

Back 100

fecal-oral spread. AIDS related and similar to cryptosporidium in sx; although responds to bactrim

Front 101

Necator Americanus (hookworm)?

Back 101

larva pierce skin from soil -> blood -> lung -> trachea -> esophagus -> small bowel. microcytic anemia, eosinophilia, cough, fever, diarrhea. Stool for O+P. Tx with mebendazole or pyrantel pamoate and Iron

Front 102

Enterobiasis (pinworm)

Back 102

ingest eggs -> adult worm. Females crawl out to anus to lay eggs. pruritus ani, UTI, vaginitis. Tape to anus. Tx with mebendazole or pyrantel pamoate, repeat in 2 weeks, tx whole family

Front 103

Diarrhea in AIDS?

Back 103

typical causes + CMV, AIDS enteropathy, crypto, Isospora, Aeramonas, M. avium; can be multiple causes at once

Front 104

Charcot's triad?

Back 104

fever, jaundice, abdominal pain

Front 105

Reynold's pentad?

Back 105

Charcot's triad + AMS and shock

Front 106

Gallstone ileus... cause, findings?

Back 106

stone erodes through GB wall into duodenum -> lodges in ileocecal valve; pneumobilia, SBO, and stone in the GI tract

Front 107

Acalculous cholecystitis

Back 107

found post-op, post-partum, burns, major trauma, vascular disease, dm, sepsis and chf

Front 108

Sentinal loop of bowel in the RUQ on x-ray?

Back 108

cholecystitis

Front 109

Pneumobilia?

Back 109

air in biliary tree, usually requires a biliary enteric fistula, infection, neoplasm, or gangrenous cholecystitis

Front 110

Sequence of events in viral hepatitis?

Back 110

LFTS -> constitutional sx -> icteric phase (itching, dark urine) -> hepatosplenomegaly -> recovery (3-4 months total)

Front 111

Hep A infection... route, serological determinate?

Back 111

fecal- oral RNA virus; IgM = acute infection, IgG = past infection

Front 112

HepB... type of virus, chronicity rate, percentage of fulminate liver failure, long term risk?

Back 112

DNA, 10% of adults, 90% of infants, 1% get fulminate failure; hepatocellular carcinoma

Front 113

Hep B s-Ag?

Back 113

means current infection, either acute or carrier state

Front 114

Anti-HBsAg?

Back 114

Antibody to HBsAg; means either old infection that did not become chronic, or vaccination; either way it means immunity.

Front 115

HBcAg?

Back 115

core antigen- present only in very early infection in the serum, later only in hepatocytes. If present in blood (regardless of HBsAg) means very recent infection

Front 116

HBeAg? Anti-HBeAg?

Back 116

marker of viral replication; if (+) in serum then pt is highly infective. Anti-HBeAg means low infectivity

Front 117

IgM anti-HBcAg?

Back 117

means infection was recent

Front 118

HepC, viral type, serologic marker?

Back 118

RNA virus; anti-HCV means chronic infection; this occurs in up to 85% of people; cirrhosis and hepatocellular CA common

Front 119

Hep E?

Back 119

similar to hep A; does not have chronic state. Higher mortality than A, especially in pregnant women

Front 120

Hep D?

Back 120

can only occur in association with HBV. Concurrent infection has better prognosis than superinfection; can become chronic and hasten cirrhosis

Front 121

Lab findings in viral hepatitis?

Back 121

AST 10-100x elevated; ALT > AST, high tbili

Front 122

HAV prevention?

Back 122

vaccination prior to exposure or vaccination and IG + vaccine if within 14 days of exposure

Front 123

HBV prevention?

Back 123

Vaccination prior to exposure, or vaccination and HBIG within 7 days of exposure