Step 2 Gi Hepatobiliary

Front 1

stepwise approach to ascites:

Back 1

Na & H2O retstrxn
2. spinonolactone
3. loop diruetic (<1L/d diuresis)
4. freq abdominal paracentesis (2-4L/d, monitor renal function, only if good)

Front 2

pancreatic pseudocyst on CT

Tx

Back 2

most pancreatic pseudocysts resolve spontaneously only tap if >5cm, >6 weeks, infected, or eroding --> hemorrhage of blood vessel;
amylase can be levated because its's a soup with pancreatic juices and componenets, so when that leaks intto blood, amylase is increased

Front 3

contraindication to succinylcholine for rapid sequence intubation

Back 3

hyperkalemia (depolarization can cause signifciant K release)
pts at risk: crush, burn (rhabdomyolysis), demyelinating syndromes, tumor lysis syumdromes;
use non-depolarizing agnentts.

Front 4

how does lactulose work:

what is the alternative

Back 4

bacteria ferment it and acidify their environment, traps ammonia
alternative is neomycin : kills amomonia producing bacteria, but is nephro-ototoxic.

Front 5

Mechanism of Non-Alcoholic Liver Dz:

Back 5

Insulin Resistance --> Fat accumulation --> increased lipolysis --> oxidative stress
Dx: Bx

Front 6

Palpable mass through abdomen near kidneys

Back 6

Adrenal masses are almost never palpable. if you can papate something you're palpating kidney.

Front 7

Rectal Examination reveals fluctuant mass at the tip of the finger

dz, tx

Back 7

pelvic abscess in rectovesicular pouch.
you can feel the whole prostate
likely 2*/2 appendicitis
tx: drainage

Front 8

SAAG

Back 8

Serum-Ascites Albumin Gradient Gradter than 1.1 is indicative of portal hypertension as the etiology for ascites (vs pancreas)

Front 9

best dx test for sigmoid diverticulitis

Back 9

Abdominal CT

Front 10

High Amplitude Peristaltic Esophageal Contractions with Normal LES relaxn

Dz, Dx, Tx

Back 10

Diffuse Esophageal Spasm
eosphagram usually normal
classical: "corkscrew" esophagus
2*/2 emotional disorders & functional GI disorders
Dx: manomoatry
Tx: antispasmotic, dietary modulation, counseling; CCCBs & nitrates

Front 11

birds beak narrowing of distal esophagus

Back 11

achalasia

Front 12

Diverticulitis:
classes and courses

Back 12

Uncomplicated: no abscess: oral antibiotics & bowel rest
Complicated:
<3cm abscess: IV abx
>3cm: CT guided ddrainage
no success --> sugical debridement
surgery for fistulas, perforation, obstrx, recurrent

Front 13

dyspepsia workup

Back 13

Dyspepsia: non-heart burn epigastric piain, fullneess/early satiety, bloating or nausea
Red Flags: weight loss, persistent vomiting, dysphagia, occult blood, odynophagia, FHx)
without Red flags: test for H pylori serology if prevelently endemic
if negative or not endemic: 8 week trial with PPI's & Follow Up

Front 14

Familial Cholelithiasis

Back 14

think Hereditary spherocytosis
all these pts need folate supplementation

Front 15

Drugs which cause pancreatitis:

Back 15

metronidazole, tetracycline
AIDS pts: didanosine, pentamidine
Seizures/Bipolar: Valproate
Immunosuppressants: Sulfalazine, 5-ASA
Diuretics: Thiazides & Furosamide

Front 16

MCC: Rectal Bleeding in elderly vs Frank Rectal Hemorrhage in elderly

Back 16

MCC: Rectal Bleeding in elderly, angiodysplasia
MCC: Frank Rectal Hemorrhage in elderly, diverticulosis

Front 17

Ludwig's Angina:

Back 17

Strep + anaerobes
MCC Death = Asphyxiation
Tx: remove tooth (source) + antibiotics

Front 18

asx gallstones

course of action

Back 18

only 20% of pts with asx gallstones will dvlp sx or complciations --> do nothing
only remove prophlyactically if at risk for CA or complixsn: morbidly obese underoign Gastric Bypass and those with procelain gallbladders

Front 19

Indications for ERCP:

Back 19

-interventional for gallstone pancreatitis
-diagnosis of choronic pancreatitis, dx of ampulaltory ca's need ts samples, need bile duct exploration

Front 20

Crigler-Najjar:

Back 20

Type 1: two bad copies --> unconjugated hyperbilirubinemia --> must have liver transplant
type 2: one bad copy --> almost always okay, some phenobarbital or clofibrate to reduce serum bilirubine levels prn;
CJ2: <20, gilbert's <3

Front 21

Tx: diabetic gastroparesis:

Back 21

improveged glycemic control
small freq meals
DA agonists (metoclopramide, domperidone)_ before meals
bethanechol
erythromycin (normally produces diarrhea, this is from interation with motilin receptors)

Front 22

Confirming Diagnosis of mesenteric angina

Back 22

angiography or doppler US

Front 23

15% of acute pancreatitis pts are complicated by

Back 23

by ARDS

Front 24

What is Reye Sro:
Tx?

Back 24

Fatty liver with Encephalopathy
Viral Illnesses treated with Aspirin
Fatty vacuolization of liver s inflammation
constellation of : elevated AST&ALT, elevated ammonia, PT prolongation, hypoglycemia, metabolic acidosis
Mortality: 1/3
Tx: glucose + FFP + [mannitol vs cerebral edema]

Front 25

Acute Pancreatitis Pt becomes hypotensive, pathology?

Back 25

most likely increased vascular permeability from enzyme spillage
if bleeding look for signs (Cullen, Grey Turner)

Front 26

Ulcerative cholitis with RUQ pain, biliary Sx
Dz, Dx, Tx

Back 26

immediately think Primary Sclerosing Cholangitis
Confirm Dx with cholangiographic "Beading" of bile ducts
Tx: control with ursodeoxycholic acid, dilation & stenting; ultimate tx is transplant
Survival is 12 years from Dx due to hepatic failure

Front 27

Pre-cirrhotic alcoholic liver px:

Back 27

dz will completely reverse with abstinence from ETOH (as long as not fully cirrhotic)

Front 28

Potassium Chloride pills complications

Back 28

pill esophagitis from

Front 29

Hepatic Encephalopathy superimposed on Acute Hepatitis
course of action

Back 29

80% mortality, high priority candidate for liver transplantation

contrad by non-hepatic likely causes of death or drug/etoh abuse

Front 30

Noncaseating Granulomas

Back 30

are pathognomonic for Crohns
when differentiating Crohns vs UC

Front 31

D-xylose test:

Back 31

D-xylose is a simple sugar which only requires access to mucosa to be absorbed
ie: it will still be absorbed with pancreatic & hepatic insufficiency
normally a person ingests 25mg and excretes >4.5g within next 5 hours
non-excretion = non-absorption = either celiac dz or bacterial overgrowth
bacterial overgrowth responds to abx

Front 32

cirrhosis with varices

Back 32

anyone with cirrhosis should get an endoscopy to screen for esophageal varicies
anyone with asymptomatic esophageal varices should be started on beta blockers prophylactically

Front 33

Hepatic Adenoma Lab Abnormalities:

Back 33

Possibly elevated AP & GGT
Dx: CT + AFP levels to monitor for malignant transformation (10% of time)
Bx: hepatocytes w/ glycogen & fat (normal looking) but lacking tissue architecture (ducts/septa, etc)

Front 34

Acalculus colechystitis:

Back 34

critically ill noncommunicative pts
imaging: thickend GB wall & pericholecytic fluid
EMERGENT --> SEPSIS --> DEATH
Tx: IV ABx + Interventional Radiology percutaneous cholecystostomy

Front 35

Choledochal cysts

Back 35

: congenital abomalies
dilation of biliary ducts
weakness of wall due to reflexu of alkaline pancreatic secretions

Front 36

Transaminases & PT as indicators of post-Hepatitis Liver fnx

Back 36

Transaminases Decreases + Stable PT = Recovering Liver
Transaminases Decrease + Increasing PT = Hepatocytes mostly dead, decreased number dying = decreased transaminases; liver function markedly deteriorate = increased PT.

Front 37

Dubin Johnson Sro vs Rotor sro:

Back 37

conjugated hyperbilirubineamias
both benign disorders of bile secretion
DJ is pigmentedhepatocytes, rotor is not.

Front 38

acute ascending cholangitis course of action

Back 38

= ERCP, not surgery
much lower morbidity with ERCP

Front 39

melanosis coli

Back 39

dark brown discoloration of colon with lymph follicles shining through as pale patches
diagnostic of factitious diarrhea
pigment macorphages in lamina propria
4 months from use of laxatives to melanosis coli [only with anthraquinone containing laxatives like bisacodyl), 4 months to resolution after last use

Front 40

dark brown discoloration of colon with lymph follicles shining through as pale patches

Back 40

melanosis coli

diagnostic of factitious diarrhea
pigment macorphages in lamina propria
4 months from use of laxatives to melanosis coli [only with anthraquinone containing laxatives like bisacodyl), 4 months to resolution after last use

Front 41

Pancreatitis Imaging:

Back 41

no imaging for acute pancreatitis until fail to respond to conservative treatment then CT
Diagnosti test for chronic pancreatitis best established by imaging best established by calcification

Front 42

Tx: varices

Back 42

sclerotherapy/band ligation & surgery are all not indicated until after a variceal bleeding. they are not prophylaxisis; Protostystemic shunt is the last resort as it worsens encephalopathy.
Non bleeding varices are managed with propranolol. This reduces bleeding risk by half.

Front 43

ZE: diagnoisis

Back 43

is fasting gastrin >1k

Front 44

MCSro assoc. w/ Increased Gastric Folding & Duodenal Ulcers

Back 44

Zollinger-Ellison Sro (GastrinOMA) <-- MEN I: 1* hyperparathyroidism, pituitary rumors & pancreatic tumors

Front 45

Hydatid Cyst

Back 45

means Echinococcus tapeworm infection - sheep *7 dogs
Tx: controversial, basically resect because they can all bleed or undergo malignant transformation

Front 46

suspected esophageal perf

Back 46

when you'd like to perform both barium swallow and endoscopy for difficulty swallowing
perform the swallow first - because maybe esophagus is tortuous stricture or something you would perf.

Front 47

inflam bowel dz vs EHEC:

Back 47

inflam bowel >4 wks

Front 48

Mallory Weiss Bleeding Stops Spontaneously in ?%

Back 48

90% of pts

Front 49

Mechanisms of hepatic encephalopathy:

Back 49

1. accumulation of ammonia
2. prodxn of false neurotransmitter
3. increased sensitivity to inhibiotry neurotransmitters like GABA
4. Zinc deficiency
NB: charactreristic delta waves on EEG

Front 50

Potential COmplications of Acute Pancreatitis:

Back 50

Left-Sided Pleual Exudative Effusion
Abd Compartment Sro
IntraAbd hemorrhage
Shock
Diabetes,
Pancreatic Pseudocyst
Abdominal Pseudoaneurysm

Front 51

Anytime you have epigastric pain

Back 51

include pancreatitis in your DDx

Front 52

Causes of Drug Induced Esophagitis

Back 52

(ie direct caustic injury to esophagus)
Antibiotics: Tetracyclines
Anti-inflam: NSAIDS & Aspirin
Bisphosphonates: Alendronate
Others: KCl, quinidine, iron

Front 53

pt with sx cholelithiasis does not want surgery

Back 53

--> ursodeoxycholic acid & avoid fattty foods
ursodeoxycholic acid reduces hepatic secretion of cholesterol & slowly dissolves stones
expensive & stones recur

Front 54

Hepatorenal Sro:

Back 54

Renal Failure of unknown cause (likely vasodilatory) from Hepatic Failure
Support: Vasporessin, Vasoconstrictors, Albuin
Treatment: Liver Transplant is only Definitive Treatment

Front 55

UC monitoring

Back 55

: colonoscopy every year after 8th year since dx

Front 56

Fleshy immobile mass midline hard palate

Back 56

Torus Palatinus
benign, ulcerates from poor vascular supply
surgical exision if symptomatic
congenital, may grow thorughout life

Front 57

Why Steatorrhea in ZE Sro?

Back 57

Gastrin --> Acidification of Stomach --> inactive pancreatic enzymes

Front 58

ulcer locations

Back 58

Acid hurts ulcers
gastric ulcers get worse with eating
duodenal ulcers get better with eating (pancreatic HCO3)
duodenal ulcers higholy associated with H pylori

Front 59

traumaticly induced duodenal hematoma

Back 59

Tx: NG tube, NPO & parenteral nutrition
ie best management is conservative, no need for abx, surgical only if failure of conservative measures

Front 60

how different drugs cause hepatic damage:

Back 60

cholestasis: chlorpromazine, nitrofurantoin, erythromycin, anbolic steroids
fatty liver: tetracycline, valproate, anti-retrovirals
hepatitis: halothane, phenytoin, INH, alpha methyldopa
toxic/fulminant liver failure: carbon tetrachloride, acetaminophen
granulomatous: allopurinol, phenylbutazone

Front 61

Pt OD's on acetaminpophen, course of action:

Back 61

<4hours: administer charcoal (not useful thereafter)
@4hours: draw actetaminophen lvels (not accurate beforehand)
thereafter: determine & administer loading dose of N-acetyl cysteine (no change in efficacy so long as given within 8 hours of ingestion)