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199 Cards in this Set
- Front
- Back
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The four important causes of viral gastroenteritistibc
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Norovirus, rotavirus, adenovirus, astrovirus
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MCC of viral gastroenteritis in adults
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Norovirus
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MCC of viral gastroenteritis in children
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Rotavirus
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Labs: viral gastroenteritis
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Negative for fecal leukocytes, fecal blood, stool culture
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Classic gastroenteritis bug: fried rice
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Bacillus cereus
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Classic gastroenteritis bug: poultry
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Campylobacter jejuni
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Classic gastroenteritis bug: recent abx
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C. diff
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MC food-borne bacterial GI bug
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Salmonella
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Classic gastroenteritis bug: pork
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Yersinia enterocilitica
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Bacterial causes of bloody diarrhea
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Campylobacter, enterohemorrhagic E. coli, Salmonella, Shigella, Yersinia, ?C. diff
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Triad of HUS
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AKI, thrombocytopenia, hemolytic anemia
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Tx: severe Shigella
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TMP-SMX
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Abx tx: V. cholera
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Tetracycline OR doxycycline
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Abx tx: C. jejuni
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Erythromycin
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Parasitic causes of bloody diarrhea
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Entamoeba histolytica
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The two pork parasites
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Trichinella and Taenia
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Dx: + acid-fast stool in pt with profuse, watery diarrhea
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Cryptosporidium
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Tx: Cryptosporidium
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Nitazoxanide
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Tx: Entamoeba histolytica
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Metronidazole
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Tx: Giardia
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Metronidazole
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Tx: Trichinella
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Albendazole
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Tx: Taenia solium GI infection
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Praziquantel
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Tx: neurocystercercosis
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Albendazole + GC
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Classic presentation: Trichinella
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Myalgias, periorbital edema, eosinophilia
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Classic gastroenteritis bug: soft cheese
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Listeria
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Two main possible bugs: GI symptoms within 6 hours of ingestion
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S. aureus of B. cereus
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Fever with GI symptoms suggests one of which three bacteria?
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Main invasive bugs: Salmonella, Shigella, Campylobacter
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Lab findings suggestive of bacterial diarrhea
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Fecal leukocytes, fecal blood, fecal lactoferrin,
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Three MCC of bacterial diarrhea in US
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Salmonella, Shigella, Campylobacter
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Which specific cause of bacterial diarrhea is an absolute contraindication to abx tx?
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Enterohemorrhagic E. coli
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Tx: Listeria monocytogenes
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Amp/gen OR TMP/SMX
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Empiric tx for non-EHEC diarrhea
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Fluoroquinolone
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Presentation: acute viral hepatitis
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Fatigue, N/V, anorexia, fever, dark urine, acholic stools, jaundice, pruritus
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Serologic diagnosis: HAV
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Anti-HAV IgM (acute) or IgG (resolved)
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Serologic diagnosis: HCV
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Anti-HCV Ab; HCV PCR
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Tx: HAV
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Supportive
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Tx: HCV
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Peginterferon + ribavirin
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Dx: acute HBV infection
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+ HBsAg and + HBeAg and + IgM HBcAb and + HBV DNA
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Dx: previous HBV infection
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+ HBsAb and + HBV IgG and – HBV DNA
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Dx: HBV vaccination
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+ HBsAb ONLY
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Dx: chronic HBV infection
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+ HBsAg and + IgG HBcAb and + HBV DNA
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Interpretation: HBeAg
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Marker of active replication and infectivity
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Dx: window phase HBV infection
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IgM HBcAb and HBV DNA
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Pharmacologic management: esophageal motility disorders (e.g. diffuse esophageal spasm)
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CCB, TCA, or nitrate
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3 MC GERD sx
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Heartburn, regurgitation, dysphagia
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5 atypical GERD sx
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Chest pain, water brash, globus sensation, bronchospasm, chronic cough
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Dx: GERD
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Clinical dx unless refractory to therapy, then pH monitoring +/- EGD
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Tx: GERD
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Initially, weight loss, elevate the head of the bed, remove dietary triggers; then H2 blockers; then PPI
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Epidemiology of esophageal cancer
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Adeno in western world, squamous elsewhere
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Classic side effects of cimetidine
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Gynecomastia and impotence
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Risk factors for esophageal cancer
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Smoking and EtOH, GERD, obesity
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Tx: esophageal cancer
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Esophagectomy for early stages; chemo/XRT in nonoperative cases
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95% of hiatal hernias are of the ___ type
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Sliding
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Major complication of hiatal hernia
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Gastric incarceration
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5 major causes of acute gastritis
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NSAIDs, alcohol, corrosive agents, severe stress, and H. pylori
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90% of chronic gastritis cases are classified as type __.
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Type B
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Location: type A gastritis
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Fundus
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Pathology: type A gastritis
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Parietal cell autoantibodies
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Labs: type A gastritis
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Hypochlorhydria, high gastrin
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Location: type B gastritis
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Antrum/body
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Pathology: type B gastritis
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H. pylori
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Labs: type B gastritis
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Hyperchlorhydria
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Define: Curling ulcer
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Associated with severe burns
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Define: Cushing ulcer
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Associated with intracranial injury
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H. pylori triple therapy
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PPI + clarithromycin + amoxicillin
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Three primary causes of PUD
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H. pylori, NSAIDs, and smoking
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Dx: PUD
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EGD
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MC locations for gastrinoma
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Pancreas and duodenum
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Two tests for gastrinoma
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Serum gastrin and serum secretin (both elevated)
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If you find a gastrinoma, look for…
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Other neuroendocrine tumors as a part of MEN1
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Patients must stop ___ in order to have an accurate serum gastrin level
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PPIs
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Stomach cancer risk factors
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Salts and nitroso compounds; smoking; H. pylori; type A blood
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Leser-Trelat sign
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Diffuse seborrheic keratoses associated with GI cancer
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Tumor markers: gastric adenocarcinoma
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CEA, 2-glucuronidase
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Tx: stomach cancer
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Subtotal gastrectomy for tumors within distal 1/3
Total gastrectomy for proximal, middle, or invasive tumors Adjuvant chemo/XRT |
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Classic pathology: celiac sprue
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Blunted villi and crypt hyperplasia
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Two celiac tests with highest accuracy
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Anti-endomysial and anti-TTG abs
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Features of tropical sprue
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Chronic diarrhea +/- malnutrition in a person who has lived in a tropical locale for 1+ months
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4 classic extraintestinal S/Sx of malabsorption
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Glossitis, cheilitis, protuberant abdomen, pedal edema
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Tx: tropical spure
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Tetracycline and folate for 3-6 months
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Positive Sudan stool stain indicates…
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Steatorrhea
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Primary metabolic fuel for colonocytes
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Short-chain fatty acids
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Four major vitamins/minerals absorbed in the duodenum
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Folate, Fe, Mg, Ca
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Absent/minimal rise in serum glucose following PO bolus of lactose indicates ____
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Lactase deficiency/lactose intolerance
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S/Sx tetrad of Whipple’s disease
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Arthralgias, weight loss, diarrhea, abdominal pain
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Extraabdominal manifestations of Whipple’s disease
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CNS (dementia, ataxia, etc) and endocarditis
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Pathognomonic pathology: Whipple’s disease
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PAS+ foamy macrophages
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Tx: Whipple’s disease
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Ceftriaxone, then TMP-SMX for 1 year
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Acute diarrheal illness associated with high fever, hematochezia, or long duration is more likely to be ___ than _____ in etiology
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Bacteria/parasitic/protozoan than viral
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Classic dx: chronic diarrhea with low pH
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Lactase deficiency
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Differential: + d-xylose test
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Small bowel bacterial overgrowth; celiac or tropical sprue; Whipple
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Explain: d-xylose test
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Simple sugar normally completely absorbed in gut and excreted in urine; GI excretion indicates malabsorption
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Equation: stool osmotic gap
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290 – 2(Na + K)
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Normal stool osmotic gap
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<50
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Elevated stool osmotic gap
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>125
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Causes of elevated stool osmotic gap
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Malabsorption, pancreatic disease
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Cause of normal stool osmotic gap
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IBS
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IBS dx criteria
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Pain relief w/ defecation; increased stool frequency with pain; loose stools with pain; feeling of incomplete defecation
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Tx: IBS
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Fiber, antispasmodics, antidepressants, Zofran
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Which type of IBD is classically associated with bloody diarrhea?
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UC
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Classic immunologic labs with Crohn’s
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+ASCA, -pANCA
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Classic immunologic labs with UC
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-ASCA, +pANCA
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4 complications of Crohn’s
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Abscess, fistulas, fissures, strictures
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2 complications of UC
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CRC, toxic megacolon
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Extraintestinal manifestations of IBD
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Arthritis, uveitis, erythema nodosum, pyoderma gangrenosum, primary sclerosing cholangitis,
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3 manifestations of perianal disease in Crohn’s
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Perianal pain, large skin tags, fissures
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Dx: IBD with rectal sparing
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Crohn’s
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3 MCC of bowel obstruction
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Tumor, adhesion, hernia
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Plain film in ischemic colitis
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Thumb-printing
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How long do the various parts of the GI tract take to recover from postoperative ileus?
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Stomach in 24hr, small bowel in 48-72hr, colon in 3-5 days
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MCC of lower GI bleed in older adults
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Diverticulosis
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Management for mild/moderate diverticulitis
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Bowel rest + cipro/flagyl
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Classic features of carcinoid syndrome
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Flushing, diarrhea, bronchoconstriction, R heart valvular disease
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MC locations for carcinoid tumors
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Lung, ileum, appendix
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Classic tumor distribution with HNPCC
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Proximal colon
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MC extracolonic tumor with HNPCC
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Endometrial
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Other extracolonic tumors with HNPCC besides endometrium
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Ovary, stomach, small bowel, upper GU system
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Define: Gardner syndrome
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Colonic adenomatous polyposis, bone stuff (skull and jaw osteomas), and skin stuff (epidermal cysts, fibromas, lipomas)
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Define: Turcot syndrome
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FAP + CNS tumors
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Define: Peutz-Jeghers
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Hamartomatous polyposis + mucocutaneous hyperpigmentation (mostly around the mouth)
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Potentially reasonable first step for suspected GI bleed
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NG lavage to confirm or r/o UGI origin
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6 common causes of UGIB
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PUD, varices, esophagitis, gastritis, Mallory-Weiss, vascular malformations (angiodysplasia/Dieulafoy)
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7 common causes of LGIB
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Diverticulosis, ischemic bowel, anorectal stuff (fissure/hemorrhoid), cancer, vascular malformations (angiodysplasia/AVM), IBD, infectious
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Tx: acute pancreatitis
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IVF, NPO +/- NGT, pain control, +/- meropenem if possible infection or necrosis
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Classic lab in chronic pancreatitis
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Low fecal elastase
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Recall: “Cullen sign”
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Periumbilical ecchymosis in acute pancreatitis
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Recall “Grey Turner sign”
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Flank ecchymosis in acute pancreatitis
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7 causes of pancreatitis
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Gallstones, EtOH, hyper-TG, hyper-CA, drugs, infections (MC viral), trauma
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When to treat a pancreatic pseudocyst?
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If >6 weeks old, very unlikely to resolve -> need to drain
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Pancreatic cancer risk factors
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Smoking, obesity, diabetes, alcohol, fatty diet
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Tx: pancreatic head tumor
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Whipple
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Hereditary syndromes associated with pancreatic cancer
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Peutz-Jegher, Lynch, BRCA
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MC presenting sx with exocrine pancreatic cancer
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Visceral pain, jaundice, weightless
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Recall “Courvoisier’s sign”
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Nontender palpable gallbladder
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Recall “Trousseau’s sign”
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Migratory thrombophlebitis in exocrine pancreatic tumors
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Classic “Whipple triad” of insulinoma
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Sx of hypoglycemia, lab evidence of hypoglycemia, and sx improvement with carbohydrates
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Sx of hypoglycemia
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Tremulousness, tachycardia/palpitations, diaphoresis, AMS
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If a patient has multiple islet cell tumors (insulinoma, glucagonoma, etc.), think ___.
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MEN1
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Non-surgical management of insulinoma
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Octreotide, diazoxide
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6 findings with glucagonoma
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Diabetes; weight loss; necrolytic migratory erythema; GI sx; thrombosis; anemia
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Non-surgical management of glucagonoma
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Octreotide, IFN-a
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5 findings with VIPoma
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Secretory diarrhea, hypokalemia, achlorhydria, hypocalcemia, flushing
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Classic triad of somatostatinoma syndrome
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Diabetes, cholelithiasis, and fatty diarrhea
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Gallstone risk factors
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Age >40; female; pregnancy; FHx; obesity; OCPs; TPN
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Classic drug associated with gallstones
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Ceftriaxone
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Charcot’s triad of cholangitis
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Fever, RUQ pain, jaundice
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Reynold’s pentad of cholangitis
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Fever, RUQ pain, jaundice, hypotension, AMS
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Management of cholangitis
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Zosyn or cipro/flagyl + ERCP
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Risk factors for cholangiocarcinoma
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PSC, cholelithiasis, basically any chronic biliary tract disease
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S/Sx: primary biliary cirrhosis
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Fatigue, pruritus, skin hyperpigmentation, hepatomegaly, arthritis
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Labs: primary biliary cirrhosis
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Anti-mitochondrial Abs; +ANA; severe hyperlipidemia
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What is the pathophysiology of primary biliary cirrhosis?
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Autoimmune destruction of intrahepatic bile ducts
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S/Sx: primary sclerosing cholangitis
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Fatigue, pruritus, RUQ pain, jaundice, fevers, night sweats
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Immunologic labs: primary sclerosing cholangitis
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+pANCA; hyper-IgM; anti-smooth muscle Abs
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Medical management options for PSC
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Ursodeoxycholic acid; MTX; steroids
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Medical management options for PBC
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Ursodeoxycholic acid; MTX; colchicine
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Presentation: Gilbert syndrome
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Mild unconjugated hyperbilirubinemia after physiologic stressors such as illness, strenuous exercise, menstruation, dehydration, etc.
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Presentation: Crigler-Najjar (1 and 2)
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Persistent substantial unconjugated hyperbilirubinemia in neonates
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How do you differentiate between Crigler-Najjar 1 and 2?
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Phenobarbital lowers bilirubin in type 2 but not in type 1
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Tx: Crigler-Najjar type 1
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Phototherapy, plasmapheresis, calcium phosphate, Orlistat
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Stigmata of chronic liver disease
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Jaundice, edema, varices, asterixis, testicular atrophy, gynecomastia, telangiectasias, palmar erythema, digital clubbing, Dupuytren contractures
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Interpretation: SAAG > 1.1
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Portal HTN (cirrhosis, Budd-Chiari, CHF)
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Interpretation: SAAG < 1.1
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Non-hypertensive ascites e.g. tuberculosis, pancreatitis, nephrotic syndrome
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PPX for variceal bleeding
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B-blockers (nadolol, carvedilol), EGD tx
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Two non-classic locations for varices in portal HTN
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Renal and paravertebral varices
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Paracentesis findings in SBP
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Low glucose, high LDH
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Tx: SBP
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Cefotaxime
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Tx: hepatic encephalopathy
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Lactulose, rifaximin
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PPX: SBP
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Fluoroquinolone or TMP-SMX
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Pharmacologic tx for ascites
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Lasix + spironolactone
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6 S/Sx: hemochromatosis
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Cirrhosis, skin hyperpigmentation, DM, arthropathy, impotence, cardiomyopathy
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Iron studies in hemochromatosis
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High serum iron, low TIBC, high ferritin
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Tx: hemochromatosis
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Weekly/biweekly phlebotomy until normalized iron studies, then monthly phlebotomy; deferoxamine for chelation, if necessary
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S/Sx: Wilson’s disease
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Hepatic (cirrhosis), neurologic (dysarthria, tremor, dystonia, parkinsonism), and psychiatric (depression, personality change)
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Tx: Wilson’s disease
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Chelation (penicillamine, trientine) with Zn and B6 supplementation
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S/Sx: A1AT
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Panacinar, basilar emphysema + cirrhosis
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Tx: A1AT
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Enzyme replacement or transplant
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MC benign liver lesion
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Hemangioma
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4 paraneoplastic syndromes of HCC
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Hypoglycemia, erythrocytosis, hypercalcemia, and severe watery diarrhea
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Risk factors: HCC
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HBV/HCV; aflatoxin; hemachromatosis; A1AT; Wilson’s; etc
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Do you biopsy suspicious hepatic lesions?
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Generally not, as they tend to bleed profusely
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MC configuration of TE fistula
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Proximal esophageal atresia + distal TE fistula
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S/Sx: TE fistula
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Drooling, choking, respiratory distress, gastric distention, aspiration pneumonia
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Classic pregnancy complication for children with TE fistula
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Polyhydramnios
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Classic drug risk factor for pyloric stenosis
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Erythromycin
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Classic presentation: pyloric stenosis
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Immediate projectile postprandial non-bilious emesis with desire to feed immediately after
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Classic physical findings with pyloric stenosis
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Palpable epigastric olive; left-to-right peristaltic waves
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Classic laboratory abnormality of pyloric stenosis
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Hypochloremic hypokalemic metabolic alkalosis
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Dx: pyloric stenosis
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UGI or US
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S/Sx: NEC
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Lethargy, poor feeding, temperature instability, diarrhea, hematochezia, distention, shock
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Classic patient who gets NEC
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Low-birth-weight preterm infant gets NEC after initiating enteral milk feeds
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Common lab findings in NEC
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Acidosis with hyponatremia
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Management: NEC
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NPO, TPN, IVF, broad abx, surgical resection
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Three disorders classically associated with intussusception
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Meckel’s, Henoch-Schonlein purpura, and CF
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Classic virus associated with intussusception
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Adenovirus
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MCC bowel obstruction < 2 years of age
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Intussusception
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Classic presentation: intussusception
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Intermittent, severe, crampy abdominal pain with bloody, mucoid stools and sausage-shaped RLQ mass
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Tx: intussusception
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Enema
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Three broad causes of neonatal jaundice
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Physiologic, hepatic, and hemolytic
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